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General Notice of Loss

Person Reporting Claim

* First and last name

Insured Information

* First and last name (as appears on policy)

* Policy Number

* Address

* City/Town

* Province

* Postal Code

* Phone Number:

( ) -

*Email:

* Date of Incident:

* Time of Incident:

* Incident Location (City and Province):

* Describe what happened

* Are you submitting an auto claim? YesNo

Insured Vehicle Information

* Vehicle Make, Model and Year:

* Vehicle Plate Number:

* Vehicle Location:

* Drivable YesNo

* Details of Damage

* Name of Driver:

* Number of Passengers:

* Were there any injuries? YesNo

* Please detail who was injured and the nature of those injuries

* Number of other Vehicles Involved

Vehicle 1 Information

Driver:

Address:

City/Town:

Province

Postal Code

Phone Number:

( ) -

Number of Passengers

Insurance Company

Policy Number

Vehicle Make, Model and Year:

Vehicle Plate Number:

Vehicle 2 Information

Driver

Address

City/Town

Province

Postal Code

Phone Number:

( ) -

Number of Passengers

Insurance Company

Policy Number

Vehicle Make, Model and Year:

Vehicle Plate Number:

Vehicle 3 Information

Driver

Address

City/Town

Province

Postal Code

Phone Number:

( ) -

Number of Passengers

Insurance Company

Policy Number

Vehicle Make, Model and Year:

Vehicle Plate Number:

* Were the police involved? YesNo

Police Information

Police Force

Name of Officer

Officer Badge Number

Incident Number

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