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Automobile Claim Reporting Form


Please fill out the information below as completely as possible.  Use the "TAB" key to move to the next item.  When you click the "submit" button your information will be e-mailed to Old Republic's Claims Department.


Insured

Policy Number

Street Address

Date of loss

-- mm/dd/yy

City

Time of loss

-- hh:mm: am/pm

State

Location

Zip

Police Department

Phone

Citations 

FAX

E-mail

Description of Accident:




Our driver

Driver phone

Our Vehicle

V.I.N.

Drivable?

Yes
No

Amount of damage

Location now

Other vehicle - kind

Location

Owner -First Name

Last Name

Street Address

City

State

Zip

Phone

Drivable?

Yes
No

Operator First Name

Last Name

Street Address

City

State

Zip

Phone

Insurance company

Damage area

INJURED: First Name

Last Name

Street Address

City

State

Zip

Extent of injury

Injured was:

A Pedestrian
In Other Vehicle
In Insured's Vehicle

Age

INJURED(2) First Name 

Last Name

Work Phone

Injured was: A Pedestrian
In Other Vehicle
In Insured's Vehicle

Extent of injury

Age

Other Information:




REPORTED BY: 

First Name

Last Name

Work Phone


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Copyright 2000 [Old Republic Insurance Company - Houston Branch]. All rights reserved.
Revised: March 30, 2000