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Today’s Date:
 
Time:
 
Date of Loss:
 
Company:
 
Address:
 
Adjuster:
 
Adjusters Email Address
 
Phone Number:
 
File Number:
 
Insured:
 
Address:
 
Home Phone Number:
 
Work Phone Number:
 
Cell Number:
 
Vehicle:
 
VIN:
 
Vehicle Location:
 
Location Phone Number:
 
Deductible $:
None 
Waived
 
Deductible Type:
Collision    
Comprehensive
Other
 
Insured pays HST:
Yes                  
No
 
43 R Endorsement:
Yes                  
No
 
WOP:
Yes                  
No
 
Damage Area:
 
Comments:
 
 

Prior to assigning claim, you may wish to print a copy for your records. A copy will be emailed to you.
 
 
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