Damage Claim Form 1 No. 1 Description of Car Have you had an estimate of damage to your property? ---YesNo 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? ---YesNo Are you employed? ---YesNo 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? YesNo Was anyone injured? YesNo 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
