FIRST REPORT OF CLAIM

ALL CLAIMS THAT INVOLVE ANY TYPE OF INJURIES OR IF YOUR VEHICLE IS NON-DRIVABLE MUST BE REPORTED IMMEDIATELY TO YOUR INSURANCE CARRIER. YOU CAN GET THE NAME OF THE CARRIER AND THEIR PHONE NUMBER OFF THE ID CARD THAT WAS SENT WITH YOUR POLICY. IF YOUR CAR IS DRIVABLE OR IF THERE WERE NO INJURIES YOU CAN FILL OUT THIS REPORT. BUT, ALL CLAIMS MUST BE REPORTED TO YOUR INSURANCE CARRIER. IF YOU HAVE ANY QUESTIONS PLEASE CONTACT YOUR AGENT OR CALL OUR CORPORATE OFFICE AT 312-427-1777. YOU MUST HAVE A POLICE REPORT AND ALL THE INFORMATION REGARDING ANY OTHER DRIVERS OR PROPERTY OWNERS WHEN MAKING A 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!