Automobile Damage

Please complete all fields below and be as specific as possible

Report prepared by*

Position*

Date*

Building Name*

Building Address*

#, Street, City, Zip

Is the Garage Attended?*

Pick one!

Driver's Name*

Driver's Address*

#, Street, City, Zip

Incident Date*

Injured's Name*

Injured's Address*

If different from above address

Registrant's Address*

If different from above address

Auto Carrier*

Policy Number*

Type of Vehicle

Model*

License Plate #*

Year*

Vehicle Damage*

Describe in detail what was reported*

Were any injuries reported?*

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Give name and position of employee who inspected the damage*

Visible Handicaps*

Did Police respond

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Precinct #

Badge#

Complaint #

Aided #

Videos or Photos/Taken*

pick one!

If yes, how many?

File

Max. file size: 50 MB.

Photo(s)

Drop files here or

Max. file size: 50 MB.

Cameras*

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If yes, what locations?

Was a Service Request sent to review and archive?*

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Requested by*

Comments*

Please complete all fields below and be as specific as possible

Type of Vehicle

This form to be emailed to the DL Claims