Claims | Golden Era Insurance Agency

DATE OF ACCIDENT

TIME OF ACCIDENT

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GOLDEN ERA CLIENT:

GOLDEN ERA CLIENT NAME AND ADDRESS (AT LEAST THE NAME) [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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GOLDEN ERA CLIENT VEHICLE:

VEH #

YEAR

MAKE

MODEL

BODY TYPE

VIN

PLATE NUMBER

STATE

OWNER'S NAME

DRIVER'S NAME

DESCRIBE DAMAGE

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OUR PROPERTY DAMAGED: [PROPERTY DAMAGED:]

VEHICLE:

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

OWNER'S NAME [OTHER OWNER'S NAME]

YOUR DRIVERS NAME (IF APPLICABLE) [OTHER DRIVER'S NAME]

RESIDENCE PHONE

DESCRIBE DAMAGE

Non-Golden Era Insurance Agency Client