Today’s Date:
Time:
Date of Loss:
Company:
Address:
Adjuster:
Adjusters Email Address
Phone Number:
File Number:
Insured:
Address:
Home Phone Number:
Work Phone Number:
Cell Number:
Vehicle:
VIN:
Vehicle Location:
Location Phone Number:
Deductible $:
None
Waived
Deductible Type:
Collision
Comprehensive
Other
Insured pays HST:
Yes
No
43 R Endorsement:
Yes
No
WOP:
Yes
No
Damage Area:
Comments:
Prior to assigning claim, you may wish to print a copy for your records. A copy will be emailed to you.
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