FILE A CLAIM

1- Your Name

1- Phone

1- Loss Time

1- Alinsco Policy #

1- Loss Date

Insured - Alinsco Policy Holder

2- Alinsco Insured: First Name

2- Alinsco Insured: Middle Init

2- Alinsco Insured: Last Name

2- Alinsco Insured: Home Phone

2- Alinsco Insured: Work Phone

2- Alinsco Insured: Street Address

2- Alinsco Insured: State

2- Alinsco Insured: City

2- Alinsco Insured: Zip

Driver

2- Driver: First Name

2- Driver: Last Name

2- Driver: Date of Birth

2- Driver: License #

2- Driver: Relationship to Insured

2- Driver: Home Phone

2- Driver: Other Phone

2- Driver: Street Address

2- Driver: City

2- Driver: Sate

2- Driver: Zip

2- Driver: Insurance Company

2- Driver: Were You Injured?

2- Driver: Where were you taken?

2- Driver: Doctor's Name

2- Driver: Description of Injury

2- Driver: Number of Passengers

2- Permission to Use Vehicle?

2- Seat Belt Worn?

2- Air Bag Activated?

2- Ambulance to Hospital?

Insured's Vehicle Description

2- Insured's Vehicle: Year

2- Insured's Vehicle: Make

2- Insured's Vehicle: Model

2- Insured's Vehicle: Color

2- Insured's Vehicle: License Plate #

2- Insured's Vehicle: License Plate State

2- Insured's Vehicle: VIN Number

2- Insured's Vehicle: Point of Impact

2- Insured's Vehicle: Drivable?

2- Insured's Vehicle: Towed?

2- Insured's Vehicle: Repair Estimate

2- Insured's Vehicle: List all damaged areas of the vehicle due to this incident

Insured's Vehicle Current Location

2- Insured's Vehicle Current Location: Name of Establishment

2- Insured's Vehicle Current Location: Contact Person

2- Insured's Vehicle Current Location: Phone

2- Insured's Vehicle Current Location: Street Address

2- Insured's Vehicle Current Location: City

2- Insured's Vehicle Current Location: Zip

2- Insured's Vehicle Current Location: State

Claimant - Not an Alinsco Policy Holder

3- Claimant Not an Alinsco Insured: First Name

3- Claimant Not an Alinsco Insured: Middle Init.

3- Claimant Not an Alinsco Insured: Last Name

3- Claimant Not an Alinsco Insured: Home Phone

3- Claimant Not an Alinsco Insured: Work Phone

3- Claimant Not an Alinsco Insured: Street Address

3- Claimant Not an Alinsco Insured: City

3- Claimant Not an Alinsco Insured: State

3- Claimant Not an Alinsco Insured: Zip

Driver

3- Driver: First Name

3- Driver: Last Name

3- Driver: Date of Birth

3- Driver: Driver License #

3- Driver: Relationship to Claimant

3- Driver: Home Phone

3- Driver: Other Phone

3- Driver: Street Address

3- Driver: City

3- Driver: State

3- Driver: Zip

3- Driver: Insurance Company

3- Driver: Where You Injured?

3- Driver: Where Were You Taken?

3- Driver: Doctor's Name

3- Driver: Description of Injury

3- Driver: Number of Passengers

3- Driver: Permission to Use Vehicle?

3- Driver: Seat Belt Worn?

3- Driver: Air Bag Activated?

3- Driver: Ambulance to Hospital?

Claimant's Vehicle Description

3- Claimant's Vehicle Description: Year

3- Claimant's Vehicle Description: Make

3- Claimant's Vehicle Description: Model

3- Claimant's Vehicle Description: Color

3- Claimant's Vehicle Description: License Plate #

3- Claimant's Vehicle Description: License Plate State

3- Claimant's Vehicle Description: VIN Number

3- Claimant's Vehicle Description: Point of Impact

3- Claimant's Vehicle Description: Drivable?

3- Claimant's Vehicle Description: Towed?

3- Claimant's Vehicle Description: Repair Estimate

3- Claimant's Vehicle Description: List all damaged areas of the vehicle due to this incident.

Claimant's Vehicle Current Location

3- Claimant's Vehicle Current Location: Name of Establishment

3- Claimant's Vehicle Location: Contact Person

3- Claimant's Vehicle Current Location: Phone

3- Claimant's Vehicle Current Location: Street Address

3- Claimant's Vehicle Current Location: City

3- Claimant's Vehicle Current Location: State

3- Insured's Vehicle Current Location: Zip:

Facts - Location of Loss

4- Location of Loss: Address / Intersectionl

4- Location of Loss: City

4- Location of Loss: State

4- Location of Loss: Description of Accident

4- Location of Loss: Road Description

4- Location of Loss: Speed Limit (MPH)

4- Location of Loss: Police Report?

4- Location of Loss: Tickets Issued?

Injuries

5- Injuries: Number of People Injured?

5-Injured Person #1: First Name

5-Injured Person #1: Specify if this Person was in the Insured Vehicle, Claimant's, or a pedestrian.

5-Injured Person #1: Taken in Ambulance

5-Injured Person #1: Treatment Location

5-Injured Person #1: Doctor's Name

6- Witness #1: First Name

6- Witness #1: Last Name

6- Witness #1: Phone

6- Witness #1: Other Phone

6- Witness #1: Street Address

6- Witness #1: City

6- Witness #1: State

6- Witness #1: Zip

File a Claim

Insured - 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

Facts - Location of Loss

Injuries

Witness

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PLEASE MAKE SURE TO COMPLETE EVERY STEP OF THE FORM BEFORE CLICKING THE SUBMIT BUTTON BELLOW*

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