Claims

REPORT CLAIMS

Please provide as much information as possible to ensure the best communication.

Items marked with * are required

 

REPORTED BY: *  
Company:  
Contact Name: *  
Telephone: *  
Email: *  

REPORTED TO BRANCH: *  

INSURER
Contact Name: *
(last, first)
 
Company: *  
Address:  
City: *  
Prov / State:  
Country:  
Postal/ZIP Code:  
Telephone:  
Fax:  
Email:  
Subscription
Information:
 

   

If YES, list % and the names of all subscribers and their %:  

 

INSURED
Contact Name: *
(last, first)
 
Company:  
Address:
 
City: *  
Prov / State:  
Country:  
Postal/ZIP Code:  
Residence Telephone: *  
Business Telephone:  
Cell Phone:  
Fax:  
Email:  

 

BROKER - provide info if available
Contact Name:
(last, first)
 
Company:  
Address:
 
 
City:  
Prov / State:  
Country:  
Postal/ZIP Code:  
Telephone:  
Fax:  
Email:  

LOSS INFORMATION

Policy Number:  
Claim Number:  
Policy Expiry Date:  
Date of Loss *
(yyyy/mm/dd):
 
Policy Coverage:
Type of Loss: *
Note: CMD-click to select multiple types
 
Insured Item:  
Location of Loss:  
Circumstances of Loss:  

AUTO CLAIM

Plate Number:  
Plate Province / State:  
Make / Model / Colour:  
Year:  
VIN (Serial) Number:  
Is the car drivable?  

   

Location of Loss:  
Driver Name:
(last, first)
 
Driver Address:  
Driver Res. Phone:  
Driver Bus. Phone:  
Driver Cell Phone:  

THIRD PARTY CLAIMANTS

Claimant #1
Claimant Name:
(last, first)
 
Address:  
Phone:  
Email:  
Property Damage?  

   

Bodily Injury?  

   

Claimant #2
Claimant Name:
(last, first)
 
Address:  
Phone:  
Email:  
Property Damage?  

   

Bodily Injury?  

   

Claimant #3
Claimant Name:
(last, first)
 
Address:  
Phone:  
Email:  
Property Damage?  

   

Bodily Injury?  

   

Claimant #4
Claimant Name:
(last, first)
 
Address:  
Phone:  
Email:  
Property Damage?  

   

Bodily Injury?  

   

Specific Handling Instructions:  
   
   

Service Locations

Doing What is Right®

 

 

 

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"Insurance is simply a promise until an event occurs...then likely as not you will need the help of an insurance professional adjusting firm. We have been partnering with Kernaghan Adjusters for over 20 years." More.