Auto Claim

To expedite the processing of your claim, please complete this notice with as much information as you have available.

Contact Information

Name: *
Daytime Phone Number: *
Fax Number:
Email:
Best Time to Call: *

Insured Information (for Business Customers only)

Company Name:
Address:
City:
State:
Zip Code:

Accident Information

Date of Accident: *
Accident Location: (Please indicate street/intersection/location, city, and state.) *
Brief Description of Accident: *
Police Contacted? *	Yes No
If so, Which Police Department:
Report Number (if available):

Insured Driver Information

Is the driver involved in the accident the same as the contact noted above? If no, please complete the information below. *	Yes No
Name:
Daytime Phone Number:

Insured Vehicle Information

Year: *
Make: *
Model: *
VIN#:
Damage to Vehicle: *
Where Can Vehicle Be Seen?

Other Driver Information

Name:
Address:
City:
State:
Zip Code:
Daytime Phone Number:

Other Vehicle Information

Year:
Make:
Model:
Damage to Other Vehicle:
Where can vehicle be seen?

Injury Information

Were injuries sustained?	Yes No
If yes, please describe:

Witness Information

Please enter name, address and daytime phone numbers for each witness.

Additional Comments

Please enter any additional comments you feel we need about this claim.

* = Required Field

You will be contacted by a representative of Kinker-Eveleigh Insurance Agency within 24 hours of our receipt of this form. If you do not hear from us, please call our office at (513) 891-6615. Please note that submission of this form does not constitute notice of a claim to either Kinker-Eveleigh Insurance Agency or your respective insurance company until confirmed by Kinker-Eveleigh Insurance Agency or your insurance company.

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