Claims | Golden Era Insurance Agency

Golden Era Insurance Agency Client

DATE OF ACCIDENT

TIME OF ACCIDENT

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INSURED:

INSURED NAME AND ADDRESS (AT LEAST THE NAME)

BUSINESS PHONE

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LOSS:

LOCATION OF ACCIDENT (INCLUDE CITY & STATE)

DESCRIPTION OF ACCIDENT

AUTHORITY CONTACTED

REPORT#

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INSURED VEHICLE:

VEH #

YEAR

MAKE

MODEL

BODY TYPE

VIN

PLATE NUMBER

STATE

OWNER'S NAME

DRIVER'S NAME

RESIDENCE PHONE

DATE OF BIRTH

DRIVER'S LICENSE NUMBER

STATE

USED WITH PERMISSION:

DESCRIBE DAMAGE

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PROPERTY DAMAGED:

VEHICLE:

DESCRIBE PROPERTY (IF AUTO: YEAR, MAKE, MODEL, PLATE)

OTHER OWNER'S NAME

RESIDENCE PHONE

OTHER DRIVER'S NAME

RESIDENCE PHONE

DESCRIBE DAMAGE

Contact Info

Golden Era Insurance Agency Client

Golden Era Insurance Agency Client

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