Fillable Printable Auto Claim Form
Fillable Printable Auto Claim Form
Auto Claim Form
AUTO CLAIM FORM
PLEASE FAX ALL CLAIMS TO: Princeton:
GR MURRAY AGENCY/ATTN: MARY ANN WILLEVER
FAX #(609) 924-9221 VOICE #(609) 924-5000 X#103
Chatham:
OGY AGENCY / ATTN: BEVERLY MCKEEVER
FAX #(973) 635-1490 VOICE #(973)-635-1800 X#257
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Date of Accident: _______________
Time: ___________ AM/PM
Police Dept Notified: _______________________
Case #: _____________________
VEHICLE #1
: (Insured’s Vehicle)
Type of vehicle: __________________
Year: __________ Make:_____________ Model: ________
VIN # __________________________________
License Plate # __________________
DRIVER/NAME/ADDRESS/#: ______________________________________________________
Email Address: .
Description of Damages: ______________________________________________________
Body Shop Information (if taken)
Address: .
Phone: .
VEHICLE # 2
: (other Vehicle)
Insurance Info: Company:___________________________
Policy # _______________________
Type of Vehicle: ______________
Year ________ Make _____________ Model ______________
VIN # ______________________________ License Plate # ___________________
Driver Info: Name ______________________________
D/License # _________________________
Address: ______________________________
City _______________ State _______ Zip _________
Description of Damage to Vehicle: _______________________________________________________
AUTO CLAIM FORM Page 2
Description of Accident:_________________________________________________________________
Person (s) Injured:
Name: ________________________________
Address: _____________________________________
City/State/Zip Code: ___________________________________________________________________
Phone# ___________________________ Vehicle # 1 or 2
Nature of Injuries: ____________________________________________________________________
______________________________________________________________________________________
Person (s) Injured:
Name: ___________________________________
Address: ___________________________________
City/State/ Zip Code: __________________________________________________________________
Phone # ____________________________
Vehicle # 1 or 2
Nature of Injuries: ____________________________________________________________________
