Insurance Accident Document

INSURANCE ACCIDENT DOCUMENT

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Policy Details

Coverage Amount:    Deductible:    Premium:

Policy Period: From to

Accident / Loss Details

Date of Loss:    Time of Loss:

Injuries & Damage

Estimated Property Damage:    Medical Treatment Sought: Yes

Witnesses

Coverage Claimed (select all that apply)

Collision    Comprehensive    Liability

Medical Payments    Uninsured/Underinsured Motorist    Personal Injury Protection

Rental Reimbursement    Towing & Labor

Documentation Checklist

Police Report    Photographs    Repair Estimates

Medical Reports & Bills    Witness Statements    Receipts / Other Bills

Exclusions & Acknowledgment

The insurer's obligations are subject to the terms, conditions and exclusions of the applicable policy. Typical exclusions include, without limitation, losses resulting from intentional acts, use of a vehicle for unauthorized commercial activity, operation by an unlicensed operator, or losses excluded by specific endorsement. Coverage determination will be made in accordance with the policy language.

I acknowledge that I have read and understand the potential exclusions described above and that coverage is subject to policy terms.

Beneficiary Designation (Accidental Death Benefit only)

Beneficiary Name:    Relationship:

Allocation Percentage:    Contact:

Declaration, Authorization and Certification

I certify that the information provided in this document is true, complete and correct to the best of my knowledge and belief. I understand that any material misstatement, omission, or fraudulent claim may result in denial of benefits, termination of coverage and civil or criminal penalties. I agree to cooperate with the insurer's investigation and to provide additional documents or information as requested.

I authorize any medical provider, employer, insurer, financial institution, law enforcement agency, or other person or entity to release to the insurer any records or information reasonably required to evaluate this claim, including medical, employment and billing records. I consent to the insurer obtaining copies of records and to the release of information necessary to pursue subrogation or recovery against responsible third parties. Payment of any claim is subject to receipt and verification of all required documentation and compliance with policy provisions.

For Insurer Use Only

Date Received:    Initial Reserve:

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