Auto Claim - Griffin Insurance

Date of loss and Time:

Contact Information

First Name:

Email:

Last Name:

Home Tel #:

Address:

Bus Tel #:

Social Sec #:

Where to Contact:

When to Contact:

Loss

Location of accident:
(City and State)

Violations/Citations:

Authority Contacted:

Report Number:

Description of Accident:

Your Vehicle

# of Vehicles:

Year:

Make:

Model:

Plate #:

State:

Owner's Name and Address

First Name:

Address:

Last Name:

Home Tel #:

Bus Tel #:

Driver's Name and Address (check if same as owner)

First Name:

Home Tel #:

Last Name:

Bus Tel #:

Relation to Insured:

Date of birth:

Driver's License #:

State:

Purpose of use:

Used with permission:

Yes No

Describe Damage:

Estimate Amount:

Where can vehicle be seen?:
When can vehicle be seen?:

Other insurance on vehicle:

Property Damage

Describe property: (if auto, year, make model, plate #)	Other Vehicle or property insurance:	Yes No
	Company or Agency Name:
	Policy Number:

Owner's Name and Address

First Name:

Address:

Last Name:

Home Tel #:

Bus Tel #:

Other Driver's Name and Address (check if same as owner)

First Name:

Home Tel #:

Last Name:

Bus Tel #:

Describe Damage:

Estimate Amount:

Where can damage be seen?:

Who was injured?

Where you (the insured) injured?

Yes

Describe your injuries:

Statement that the claimant agrees that all the information submitted in this form is truthful, and that they understand fraudulent claims are illegal and can be prosecuted by law etc etc etc...