Report Claim

Date of accident:

Location of accident:

Description of accident:

Addtional comments:

Police department and case # if applicable:

Higginbotham Insured information

Driver’s first and last name:

Year, make and model of insured’s vehicle:

VIN number of insured’s vehicle:

Description of vehicle damage:

Additional comments:

Injuries?
yes  no

Third Party Claimant Information

Vehicle owner’s first and last name:

Vehicle owner’s address:

Vehicle owner’s phone number:

Driver’s first and last name (if different from owner):

Driver’s phone number (if different from owner):

Vehicle year, make and model:

Description of vehicle damage:

Injuries?
yes  no

Date of incident:

Damaged property address:

Description of damage and incident:

Do you need emergency services?
 yes no

Additional comments:

Date of accident:

Address of incident:

Description of incident:

Third Party Claimant Information

First and last name:

Address:

Phone number:

Description of property damage or bodily injury:

Additional comments:

Description of incident:

Primary contact’s first and last name:

Phone number:

Additional comments:

Date of accident:

Location of accident:

Description of accident:

Addtional comments:

Police department and case # if applicable:

Higginbotham Insured information

Driver’s first and last name:

Year, make and model of insured’s vehicle:

VIN number of insured’s vehicle:

Description of vehicle damage:

Additional comments:

Injuries?
yes  no

Third Party Claimant Information

Vehicle owner’s first and last name:

Vehicle owner’s address:

Vehicle owner’s phone number:

Driver’s first and last name (if different from owner):

Driver’s phone number (if different from owner):

Vehicle year, make and model:

Description of vehicle damage:

Injuries?
yes  no

Date of incident:

Damaged property address:

Description of damage and incident:

Do you need emergency services?
 Yes No

Additional comments:

Date of accident:

Address of incident:

Description of incident:

Third Party Claimant Information

First and last name:

Address:

Phone number:

Description of property damage or bodily injury:

Additional comments:

Description of incident:

Primary contact’s first and last name:

Phone number:

Additional comments:

Date of accident:

Location of accident:

Description of accident:

Addtional comments:

Police department and case # if applicable:

Higginbotham Insured information

Driver’s first and last name:

Year, make and model of insured’s vehicle:

VIN number of insured’s vehicle:

Description of vehicle damage:

Additional comments:

Injuries?
Yes  no

Third Party Claimant Information

Vehicle owner’s first and last name:

Vehicle owner’s address:

Vehicle owner’s phone number:

Driver’s first and last name (if different from owner):

Driver’s phone number (if different from owner):

Vehicle year, make and model:

Description of vehicle damage:

Injuries?
Yes  no

Date of incident:

Primary contact’s first and last name:

Phone number:

Damaged property address:

Description of damage and incident:

Do you need emergency services?
 Yes No

Additional comments:

Date of accident:

Address of incident:

Description of incident:

Third Party Claimant Information

First and last name:

Address:

Phone number:

Description of property damage or bodily injury:

Additional comments:

Description of incident:

Primary contact’s first and last name:

Phone number:

Additional comments:

Date of accident:

Location of accident:

Description of accident:

Addtional comments:

Police department and case # if applicable:

Higginbotham Insured information

Driver’s first and last name:

Year, make and model of insured’s vehicle:

VIN number of insured’s vehicle:

Description of vehicle damage:

Additional comments:

Injuries?
Yes  no

Third Party Claimant Information

Vehicle owner’s first and last name:

Vehicle owner’s address:

Vehicle owner’s phone number:

Driver’s first and last name (if different from owner):

Driver’s phone number (if different from owner):

Vehicle year, make and model:

Description of vehicle damage:

Injuries?
yes  no

Date of accident:

Address of incident:

Description of incident:

Third Party Claimant Information

First and last name:

Address:

Phone number:

Description of property damage or bodily injury:

Additional comments:

Description of incident:

Primary contact’s first and last name:

Phone number:

Additional comments: