Emergency Claim Form

Speed up claim intake after an accident: policyholder details, where and when the incident happened, injuries involved and availability for follow-up. Designed for health and auto insurers that want to respond to customers quickly.

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Name

Nombre

Apellido

Telephone Number

Mobile Telephone

Date of Accident

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Location of Accident

Do you have details of the party at fault?

Yes No Only some details

Do you have injuries

Yes No Only minor injuries

Did you visit your GP or hospital in connection with your injuries

Yes No Visit scheduled

Brief description of accident

Brief description of injuries

Preferred Availability Date/Time

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