Consumers - Magermans & Raes Insurance Brokers Ltd.

Policy Holder Information

Policy Number:

Primary Contact Person:

Home Phone:

Work Phone:

Where should we contact you?

Best time to contact you?

Accident Information

Who was driving?

Date of Loss or Accident:

Time of Accident:

Vehicle Year (yyyy):

Vehicle Make:

Vehicle Model:

Is the vehicle drivable?

Yes

No

If no, where can the vehicle be inspected?

Please provide as much detail as possible regarding the claim in the spece provided below.
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(Max 255 Words)

Did any injuries result from the Accident?

Yes

No

If yes, please provide names, addresses, phone numbers and the extent of the injuries.
(Max 255 Words)

Other Driver Information

Full Name:

Insurance Provider:

Policy Number:

Contact Phone:

Licence Plate #:

Vehicle Year (yyyy):

Vehicle Make:

Vehicle Model:

Location of Accident

City / Province:

Police Contacted?

Yes

No

Officer's Name:

Officer's Badge Number:

Report Number:

Were there witnesses?

Yes

No

Witness #1

First Name:

Last Name:

Contact Phone:

Work Phone:

Email Address:

Name of your broker: