FIRST REPORT OF CLAIM

All Claims that involve any type of injuries or if your vehicle is non-drivable should be reported direct to your agent or to our corporate office at: 312-427-1777.  Before you report a claim you must have a police report.  Also make sure you have all the information regarding any other drivers or property owners when making this report.

YOUR INFORMATION  (Policy Holder)

Account No:

First Name:  Last Name:    

Address: Apt:

City:    State:  Zip Code:

Home Phone No:   Business No:  

Your Email Address:  

TYPE OF CLAIM: Accident   Vandalism   Theft

If Theft Please List Equipment:

If Accident or Vandalism - Describe the damage to your vehicle:

Is the Vehicle Drivable?    YES          NO

If "NO" Where can we contact you in order to tow the vehicle?

Phone No:    Time:

OUR VEHICLE INFORMATION

Vehicle Year: Make:  Model:

License Plate No:     State:

OWNER INFORMATION

First Name:  Last Name:    

Address:    

City:  State:  Zip Code:

Home Phone No:    Business No:

DRIVER INFORMATION

First Name:  Last Name:    

Address:    

City:      State:     Zip Code:

Home Phone No:    Business No:  

Check if Driver same as owner

Relationship of Driver to Insured:   Family, Friend, Employee, etc.

Date of Birth:  License No:  State:

Purpose of vehicle usage:

Was vehicle used with permission?   YES   NO

VEHICLE & ACCIDENT INFORMATION

Describe Damage to your Vehicle:

Is the vehicle drivable?  YES   NO

Where can we call you?  

  Time:

Time of accident:  Date:  

  Time:

Location of accident:      Address:

     City:   State:

Describe the accident - How did it happen:

Police Dept. at scene:  

 Report No:

Violations or Citations:   Describe:

OTHER VEHICLE OR PROPERTY DAMAGED  (Not your vehicle)

Vehicle Year:   Make:  Model:

License Plate No:   Insured by:

Description of other damaged property:

OTHER OWNER INFORMATION

First Name:  Last Name:    

Address:    

City:    State:     Zip Code:

Home Phone No:         Business No:

OTHER DRIVER INFORMATION

First Name:  Last Name:    

Address:

City:    State:    Zip Code:

Home Phone No:         Business No:  

Check if Driver same as owner

Drivers License No:

Describe all damage:

INJURED PARTIES

First Name:  Last Name:    

Address:    

City:  State:  Zip Code:   Age:

Home Phone No:         Business No:

Describe Injury:

Injured was: Pedestrian  In your car In the other car

First Name:   Last Name:    

Address:

City: State:  Zip Code:   Age:

HomePhone No:         Business No:

Describe Injury:

Injured was: Pedestrian  In your car In the other car

WITNESSES OR PASSENGERS

First Name: Last Name:    

Address: 

City: State:  Zip Code:   Age:

Home Phone No:         Business No:

Describe Circumstances:

Person was: Pedestrian  In your car In the other car

------------------------------

First Name:  Last Name:    

Address: 

City:  State: Zip Code:   Age:

Home Phone No:         Business No:

Describe Circumstances:

Person was: Pedestrian  In your car In the other car

  When you drive with Northwest, you drive with the best!