Claim and Report Forms

Theft report

All questions must be answered.


Insured/policy holder information
Last name: First name: Middle initial:
Phone:
Home Address:

City: State: ZIP:
Date of birth (MM/DD/YYYY): Marital status: No. of dependents:

Business Name:
Address:
City: State: ZIP:
Loss report
Was Vehicle locked?
Specific location from which vehicle was taken:
Reason vehicle was left at this location:

Person leaving vehicle at this location:
Last name: First name: Middle initial:
Driver's license#: State:
Home address:

City: State: ZIP:

Names and addresses of others who were present:

How did you get home after the theft?
Location of police station:
Reporting officer: Badge#: Docket#:
Has vehicle been recovered:
Where?
By whom?
Did police make any arrests or have any suspects?
Vehicle information
Year / Make / Model:
VIN#: Body type: Color:
License plate #: State: Plate year:

Do you have pictures of the vehicle?
Was vehicle for sale?
Was vehicle rebuilt?

Has Vehicle been damaged in the past 3 years?  
Describe damages:
Was Vehicle repaired? By whom?

Insurance company that paid the claim:
Address:

City: State: ZIP:
Agent’s name: Phone#:
Policy#: Cancellation date:
Vehicle equipment
Check if vehicle had any of the following:
Air Conditioning
Power windows
Power steering
Power brakes
Vinyl roof
Automatic shift
Standard shift
Console
Radio:
Tape deck
CD player
Tires:
Whitewall
Radial
CB Radio:
CB Radio Type: Cost:
Date CB installed: Purchased from:
Vehicle Condition
Paint work: Transmission: Engine:
Body: Interior:
Distinguishing features (dents, decals, trailer hitch, interior work, etc.):
Service information
Routine service is performed at:
Address:
City: State: ZIP:
Phone#: Date last serviced:
Who performs state mv inspection: Date last inspected:
Vehicle purchase information
Vehicle purchase information
Purchase date (MM/DD/YYYY):  
Purchase price: $ Trade-in value: $ Allowance: $

How was vehicle for sale?
Seller’s name:
Address:
City: State: ZIP:
Phone#: Vehicle payment by:

Finance company:
Is account current?
Address:
City: State: ZIP:
Phone#: Account#: Balance due: $
Prior insurance
Did you have prior physical damage insurance?
Prior insurance company:
Company address:
City: State: ZIP:
Policy#: Phone#:
Your e-mail address:
BY SUBMITTING THIS FORM, I ASSERT THAT I HAVE ANSWERED THE ABOVE QUESTIONS AND THEY ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
  

Please notify the Insurance Systems claims department to report this claim.
Claims department phone number 1-800-749-5440

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