Automobile Claims Report

Insured's Information

If part of a larger group, i.e. a Diocese, please name your sub-group, parish, etc.

Accident Information

Location of accident:

Was there any property damage other than the vehicle? If so, please describe.

Your Vehicle

Repair shop information:

Other Vehicle

Please describe any damage done to the other vehicle.

Additional Information

Were there any injuries? If so, please include the name(s), address and phone number of any injured parties.

Were there any passengers or witnesses? If so, please include the name(s), address and phone number is possible.

If YES, please provide the accident report number and any other relevant details.

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