River Crest Insurance

Automobile Claim/Loss

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

Insured Information
Name:
Street Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email Address:
Best Time To Contact:
Contact By:
Policy Number:

Incident/Event Details
Time of Loss
Date:
Location:
Detail Description of Incident:
Were the police notified:
Department?:
Case Number?:
Were you ticketed or at fault?:
If Yes, explain:
If there were any injuries, please describe them:
Please list any witnesses and/or passengers:

Vehicle Involved
Did you damage your vehicle?:
If Yes, explain:
Where is the car located:
Year:
Make:
Model:
VIN #:
Driver's License #:
Driver License State
License Plate #:
License Plate State:
Do we insure this car?:
If No, were you using it with permission?:
Please explain:

Other Party Information
Name:
Street Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email Address:
Best Time To Contact:
Contact By:
Policy Number:
Insurance Company:
Driver's License #:
Driver License State:
License Plate#:
License State:

Describe damage to the other car:
Where is the car located:

Additional Information In the box below, please provide any additional information you feel may be necessary for us to provide you with the best quote possible such as additional operators, coverages engines, etc.