Basic Claim Info > Bodily Injury > Vehicle Damage > Property Damage > Witnesses > Contact > Confirm Claim Info
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
              Next