AUTOMOBILE  CLAIM  FORM


      We are using a Secured Server using SSL technology to insure your privacy.  If you are not comfortable sending us certain information via the Internet, you can leave it blank and we will call you to get it.

      Please complete as much of the form as possible.  If however, you do not have all the information on the other driver, just leave it blank.  We will try to get the needed information directly from the other driver or the police report.

POLICY  HOLDER  INFORMATION

Policy Holder Name:

Current Address:

City, State, Zip:

    

Daytime Phone:

Policy Number:
(Not Required)


CONTACT  PERSON

Check if contact person is the same as policy holder:

Full Name:

Daytime Phone:

Home Phone:
(Optional)

Cellular Phone:
(Optional)

Email Address:
(Optional)


ACCIDENT  INFORMATION

Date of Accident:

Time of Accident:
(Not Required)

Accident Address:

City, State, Zip:

    

Brief Description of Accident:

Police Contacted:

Police Report Number:

Police Department Name:

Were you given a ticket:
    
               Description of Ticket (Speeding, Running Light, etc...)

Was other driver given a ticket:
    
               Description of Ticket (Speeding, Running Light, etc...)

Witnesses:
(does not include anyone in your car)

 Name:  Phone:

Name:  Phone:

Did injuries result from accident:

If "Yes", please provide: Name, Address, Phone # and the Extent of Injuries:



POLICYHOLDER  VEHICLE  INFORMATION

Vehicle:
(Year, Make, Model)

Driver Name:

 Same as Policy Holder

Driver Address:

 Same as Policy Holder

City, State, Zip:

    

Driver Phone:

 Same as Policy Holder

Drivers Relationship to Policy Holder:

(Self, Spouse, Child, Friend, etc...)

Was policy holder vehicle damaged?:

If "Yes", please provide the following:

Brief Description of Damage:


INFORMATION  ON  OTHER  VEHICLE

Vehicle:
(Year, Make, Model)

Driver Name:

Driver Address:

City, State, Zip:

    

Driver Phone:

  

Owner's Name:

 Same as Driver

Owner's Address:

 Same as Driver

City, State, Zip:

    

Owner's Phone:

 Same as Driver

Was the Other Vehicle Insured:

Name of Company:

Policy Number:

Was the other vehicle damaged:

If "Yes", please provide the following:

Brief Description of Damage:

Comments or Remarks:


        






3201 New Mexico Avenue NW #205
Washington, DC 20016
Phone (202) 966-0700
Fax (202) 966-1440
insurance@howard-hoffman.com


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