Auto Insurance Claim
Auto Insurance Claim
Claimant Information
|
Full Name |
[Your Name] |
|---|---|
|
Policy Number |
ABC123456 |
|
Email Address |
[Your Email] |
Accident Details
Date and Time of Accident: October 1, 2055, at 3:45 PM
Location of Accident: 123 Main Street, Springfield, IL
Description of Accident: The accident occurred at a traffic signal when my vehicle, a 2017 Toyota Camry, was rear-ended by another vehicle.
Vehicle Information
|
Make |
Toyota |
|---|---|
|
Model |
Camry |
|
Year |
2017 |
|
Vehicle Identification Number (VIN) |
1HGBH41JXMN109186 |
Damage Assessment
-
Rear bumper damaged
-
Trunk lid dented
-
Brake lights broken
Police Report
Police Report Number: SPR20231001
Officer Name: Officer Jane Smith
Department: Springfield Police Department
Witness Information
|
Full Name |
Alex Johnson |
|---|---|
|
Contact Number |
(123) 555-7890 |
Other Party Information
|
Full Name |
Jane Roe |
|---|---|
|
Insurance Company |
BCK Insurance |
|
Policy Number |
XYZ789123 |
|
Contact Number |
(987) 654-3210 |
Supporting Documents
-
Photos of the accident scene
-
Photos of the vehicle damage
-
Police report copy
Additional Comments
I was stopped at a red light when the other vehicle struck my car from behind. The driver of the other vehicle admitted fault at the scene. I request a prompt review and settlement of my claim.
[Your Name]
