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Auto Claim
Please complete the following information. All information provided on this information sheet is confidential and will not be used for any purpose other than what it is intended.
Contact Information
First Name:
Last Name:
Contact Phone:
E-mail Address:
Policy Number:
Name of Insurance Company on Policy:
Vehicle Involved
Loss General
Date of Loss:
Cause of Damage:
Estimated Damage:
The following section is applicable to Accident only
Driver First Name:
Driver Last Name:
Relationship to Applicant:
Time of the Accident:
Number of Cars Involved:
Police Notified: Yes No
Estimated Percentage at Fault:
Location of the Accident
Short Description
Other Party Information (if available)
Other Driver Name:
Home Phone:
Work Phone:
Driver's License:
License Plate:
License State:
Insurance Company:
Policy Number:
Vehicle Year/Make/Model:
Damage Description
The following section is applicable to Theft only
Time Loss Discovered:
Date Police Notified:
Vehicle Recovered: Yes No
Date Vehicle Recovered:
Short Description
Online Claim Notice
I understand that any person who files a claim with the intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
I have read and agree with the above.

1435 W Busch Blvd. Ste. D | Tampa, FL 33612
Phone 813-931-5546
Fax 813-931-9137
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