Basic Claim Infomation |
Date of accident : | 2009/03/05 |
Time of accident : | Monoring |
Location of accident : |
NewYork |
Was anyone injured? : | Yes |
How many people injured? : | 2 |
|
Was there damage to your vehicle? : | yes |
How many vehicles involved in accident? : | 2 |
Was there damage to property other than vehicles? : | yes |
Was there a witness to the accident? : | yes |
Was Other driver's insurance information obtained? : | yes |
Was a police report filed? : | yes |
You indicated a police report was not filed; please explain why
|
not and give a brief description of the accident : |
Becuase I was late for a very important meeting and planned to report the accident later in the day after work. |
|
Bodily Injury Infomation |
Injured person choosen from named insureds on your policy : |
Others |
If injured person not in drop down list, please enter injured persons first name : |
Jhon |
If injured person not in drop down list, please enter injured persons last name : |
Smith |
Type of treatment received : |
Taken to emergency room
|
What is the name of the medical facility injured taken to? : | Shanghai Hospital |
Please give a brief description of injuries? : | The leg is broken |
Injured person choosen from named insureds on your policy : |
Sally |
If injured person not in drop down list, please enter injured persons first name : |
If injured person not in drop down list, please enter injured persons last name : |
Type of treatment received : |
Taken to emergency room
|
What is the name of the medical facility injured taken to? | NewYork Hospital |
Please give a brief description of injuries? : | The hands is broken |
|
Vehicle Damage Infomation |
vehicle involved in accident choosen from list of insured vehicles : | VIN-3
|
If vehicle not found in drop down list, enter vehicle VIN : |
1B4YEM9P4KP186543 |
If vehicle not found in drop down list, enter make : |
Toyota |
If vehicle not found in drop down list, enter model : |
Prius |
If vehicle not found in drop down list, enter model year : |
2005 |
What is the extent of damage to the vehicle? : |
Driven from scene |
Please enter a description of the damage to the vehicle : | The car is destroyed. |
Was another vehicle involved in accident? : |
no |
|
Property Damage Infomation |
Property damage description : |
Wind shield is broken |
|
Witness Infomation |
What is the witness' first name? : |
Bill |
What is the witness' last name? : |
Colison |
What is the witness' phone number? : |
13916100519 |
|
Contact Infomation |
Whom should we contact? : | Bills |
what phone number? : |
1391111111 |
What is the best time to contact? : |
Morning |
Email Address? : |
bills@ibm.com |
|
|