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429 Theater Drive ~ Johnstown, PA  15904 ~ Phone (814)-262-9833 ~ Fax (814)-262-9733~1-800-544-6680

 

Claim Report

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This page will allow you to send our agents any information from an accident that you may have had.  We will get back with you as soon as is possible.

CONTACT INFORMATION
Please provide the following contact information:
First name
Last name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
E-mail
LOSS
Enter the date of the loss :

-- mm/dd/yy

 Location of accident?
Description of accident?

 Authority contacted & report number:
Violations/Citations
POLICY INFORMATION
Bodily injury

 Property Damage
Single Limit

 Med. Pay
OTC Ded.

 Loss Payee
Collision Ded.

 Other Coverage & Deductibles
INSURED VEHICLE
Veh. No.

 Year, Make, Model
V.I.N. (Vehicle Identification)

 Plate No.
Owner's Name & Address

 Phone
Driver's Name & Address (if different from owner)

 Residence Phone#
Relation to insured?

 Business Phone#
Date of birth?

-- mm/dd/yy

 Driver's license#?
Purpose of use?

 Used with permission?

Yes
No

Describe damage:

 Estimate amount?
Where can vehicle be seen?

 When?
Other insurance on car?
PROPERTY DAMAGED
Describe Property (if auto, year, make, model, plate no.)

 Other Veh/Prop. Ins?

Yes
No

Company or Agency name & policy#
Owner's name & address:
First name
Last name
Work Phone
Home Phone
Other driver's name & address (if different)
First name
Last name
Work Phone
Home Phone
Describe damage:

 Estimate amount?
Where can damage be seen?
INJURED
Injured #1
First name
Last name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone

Extent of Injury:
 

Injured #2

First name
Last name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Home Phone
Extent of Injury:
 

Injured #3

First name
Last name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Home Phone
Extent of Injury:
WITNESS OR PASSENGERS
(Please list name, address and phone on seperate lines)

 

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Webcurator@fwf.com
Copyright © 2004 FWF Insurance Company.
Last revised: November 13, 2004