Claim Report-Auto - Capital Insurance Brokers

Your Information

Are you currently insured with our brokerage?

Yes - I am a client of the brokerage
No - I am a third party filing a claim against a client of the brokerage

Name

First Last

Primary phone number*

Secondary phone number

Email

Address*

Your policy info

Policy number*

Insurance carrier*

Please type in the name of your insurance carrier*

Please enter Year, Make and Model of your vehicle*

Please enter the VIN (serial number) of your vehicle

Other driver(s) policy info

Were there other vehicles involved in the incident?

No
1 other vehicle
2 other vehicles
3 other vehicles

Details for other vehicle #1

Please fill out any details you have for the other drivers.

Year, Make and Model of vehicle*

VIN (serial number) of vehicle

Name of driver

First Last

Please enter any contact info you have for the driver

Is this driver also the listed owner on the vehicle's insurance slip and registration?

Yes
No

Name of registered owner of vehicle

First Last

Please enter any contact info you have for the owner

Insurance policy number

Name of insurance company

License plate number

Details for other vehicle #2

Please fill out any details you have for the other drivers.

Year, Make and Model of vehicle*

VIN (serial number) of vehicle

Name of driver

First Last

Please enter any contact info you have for the driver

Is this driver also the listed owner on the vehicle's insurance slip and registration?

Yes
No

Name of registered owner of vehicle

First Last

Please enter any contact info you have for the owner

Insurance policy number

Name of insurance company

License plate number

Details for other vehicle #3

Please fill out any details you have for the other drivers.

Year, Make and Model of vehicle*

VIN (serial number) of vehicle

Name of driver

First Last

Please enter any contact info you have for the driver

Is this driver also the listed owner on the vehicle's insurance slip and registration?

Yes
No

Name of registered owner of vehicle

First Last

Please enter any contact info you have for the owner

Insurance policy number

Name of insurance company

License plate number

Loss Information

When did the loss occur?*

What time did the loss occur?

:

Please describe the incident, including WHERE it occurred and WHAT exactly happened

If there were any passengers or witnesses, please provide contact information for them

If you have filed a Police Report, please provide the police report number as well as the police force that the report was obtained from

Upload photos or documents

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 2 MB, Max. files: 10.

Please upload any files you feel are relevant (pictures, police report, etc.). Maximum 10 files, up to 2MB each.

PCR-Client: Claim: Auto

Your Information

Your policy info

Other driver(s) policy info

Details for other vehicle #1

Details for other vehicle #2

Details for other vehicle #3

Loss Information

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