File A Claim

Basic Information

Your Name

Phone Number

Loss Date

Loss Time

Alinsco Policy #

Insured

Alinsco Policy Holder

First Name

Middle Initial

Last Name

Home Phone

Work Phone

Street Address

City

State

Zip

Driver

First Name

Last Name

Date of Birth

Driver License Number

Relationship to Insured

Home Phone

Other Phone

Street Address

City

State

Zip

Driver Insurance Company

Were You Injured?

Where Were You Taken?

Doctor's Name

Description of Injury

Number of Passengers

Permission to Use Vehicle?

Seat Belt Worn?

Air Bag Activated?

Ambulance to Hospital?

Insured's Vehicle Description

Year

Make

Model

Color

License Plate #

License Plate State

VIN Number

Point of Impact

Vehicle Drivable?

Vehicle Towed?

Estimated Repair Cost

List all damaged areas of vehicle due to this incident

Insured's Vehicle Current Location

Name of Establishment

Contact Person

Phone

Street Address

City

State

Zip

Claimant

Claimant - Not an Alinsco Policy Holder

First Name

Middle Initial

Last Name

Home Phone

Work Phone

Street Address

City

State

Zip

Driver

First Name

Last Name

Date of Birth

Driver License Number

Relationship to Claimant

Home Phone

Other Phone

Street Address

City

State

Zip

Driver Insurance Company

Where You Injured?

Where Were You Taken?

Doctor's Name

Description of Injury

Number of Passengers

Permission to Use Vehicle?

Seat Belt Worn?

Air Bag Activated?

Ambulance to Hospital?

Claimant's Vehicle Description

Year

Make

Model

Color

License Plate #

License Plate State

VIN Number

Point of Impact

Vehicle Drivable?

Vehicle Towed?

Estimated Repair Cost

List all damaged areas of vehicle due to this incident

Claimant's Vehicle Current Location

Name of Establishment

Contact Person

Phone

Street Address

City

State

Zip

Injuries

Number of People Injured

Injured Person #1

First Name

Last Name

Phone

Date of Birth (or Age)

Street Address

City

State

Zip

Description of Injury

This injured person was...

Taken in Ambulance?

Treatment Location

Doctor's Name

Injured Person #2

First Name

Last Name

Phone

Date of Birth (or Age)

Street Address

City

State

Zip

Description of Injury

This injured person was...

Taken in Ambulance?

Treatment Location

Doctor's Name

Injured Person #3

First Name

Last Name

Phone

Date of Birth (or Age)

Street Address

City

State

Zip

Description of Injury

This injured person was...

Taken in Ambulance?

Treatment Location

Doctor's Name

Note Information on any additional injured persons will be taken when we contact you.

Alinsco Policy Holder

Driver

Insured's Vehicle Description

Insured's Vehicle Current Location

Claimant - Not an Alinsco Policy Holder

Driver

Claimant's Vehicle Description

Claimant's Vehicle Current Location

Location of Loss

Injured Person #1

Injured Person #2

Injured Person #3

Witness Number 1

Witness Number 2