ProductionInsurance.com | Claims Reporting


	Supple-Merrill & Driscoll, Inc.
	Insurance Agents and Brokers \| Since 1923

Non-Workers Compensation Claim Reporting Instructions

1. Claims should be reported immediately.

2. Please provide as much information as possible to expedite the claim reporting.

3. Please include a narrative of the occurrence leading to the loss.

4. Please complete this form for each loss.

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Policyholder Information
Name of Individual/Company/Organization:
Full Name of Person to Contact:
Number:
Fax:
Email:	We will never rent, sell, or share your email address.
Full Name of Person Submitting Claim:

Automobile Loss
Insured Vehicle / Insured Driver Information
Name of Vehicle Owner:
Year, Make, Model & License of Damaged Vehicle:	Rented Vehicle Non-Owned Vehicle
VIN:
Estimated Loss Value:
Driver Name:
Driver Phone Number:
Driver License Number & State of Issue:
Driver Date of Birth:
Other Vehicle / Other Driver Information
Name of Vehicle Owner:
Year, Make, Model & License of Damaged Vehicle:
VIN:
Estimated Loss Value:
Driver Name:
Driver Phone Number:
Driver License Number & State of Issue:
Driver Date of Birth:

Location of Loss
Name of Location:
Street Address:
City, State:	,
Zip/Postal Code:
Describe Location of Loss if Not at Specific Street Address:

Loss Narrative

Please provide a detailed description of the events surrounding the loss below.


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