Damage Claim Form 1

No. 1

Description of Car

Have you had an estimate of damage to your property?

If so, attach estimate. If repairs made, attach bill

Check kind of insurance carried CollisionProperty DamageLiability

Was the driver of your car on business of the owner?

Are you employed?

No. 2

No. 3: Important: Give Names and Addresses

List passengers in your car with addresses and age. If under 21, give parent's name.

Give names and addresses of all persons who witness or can furnish information regarding the accident.

No. 4

Were you injured?

Was anyone injured?

If anyone was injured, please give name, address, age, and nature of illness.

No. 5 Facts about other vehicle

Description of car

No. 6 Facts about the accident