Auto Insurance Claim
Claimant Information
Full Name | [Your Name] |
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Policy Number | ABC123456 |
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Email Address | [Your Email] |
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Accident Details
Date and Time of Accident: October 1, 2055, at 3:45 PM
Location of Accident: 123 Main Street, Springfield, IL
Description of Accident: The accident occurred at a traffic signal when my vehicle, a 2017 Toyota Camry, was rear-ended by another vehicle.
Vehicle Information
Make | Toyota |
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Model | Camry |
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Year | 2017 |
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Vehicle Identification Number (VIN) | 1HGBH41JXMN109186 |
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Damage Assessment
Rear bumper damaged
Trunk lid dented
Brake lights broken
Police Report
Police Report Number: SPR20231001
Officer Name: Officer Jane Smith
Department: Springfield Police Department
Witness Information
Full Name | Alex Johnson |
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Contact Number | (123) 555-7890 |
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Other Party Information
Full Name | Jane Roe |
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Insurance Company | BCK Insurance |
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Policy Number | XYZ789123 |
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Contact Number | (987) 654-3210 |
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Supporting Documents
Additional Comments
I was stopped at a red light when the other vehicle struck my car from behind. The driver of the other vehicle admitted fault at the scene. I request a prompt review and settlement of my claim.
[Your Name]
Insurance Claim Templates @ Template.net
