CLAIM FOR DAMAGES OR INJURY AAAA-1 AAA AGENCY 1234 56TH AVENUE SOUTH FOGARTYVILLE, MASSACHUSSETTS 12345 GENERAL INFORMATION 1. Claimant-- (a) Full name: __________________________________________ (b) Address: ____________________________________________ City: _________________________ County: _________________ State: _________________ Zip Code: _____________________ (c) Age: _______ (d) Marital status: ___________________ 2. If claimant is married, name and address of spouse: _________________________________________________________ _________________________________________________________ AMOUNT OF CLAIM 3. Amount claimed for property damage: __________________ 4. Amount claimed for personal injury: __________________ 5. Total amount claimed: ________________________________ ACCIDENT RESULTING IN CLAIM 6. Place of accident (include town or city and state; if outside city limits, indicate distance to nearest city or town): _________________________________________________________ 7. Date and time of accident: ___________________________ _________________________________________________________ (a) Day of week: ________________________________________ (B) Date: _______________________________________________ (C) Time: _______________________________________________ 8. Description of accident (a) Names and addresses of persons involved: ____________ _________________________________________________________ (b) Identification of property involved: ________________ _________________________________________________________ (c) Surrounding circumstances: __________________________ _________________________________________________________ (d) Cause of accident: __________________________________ _________________________________________________________ (e) Other pertinent facts: ______________________________ _________________________________________________________ 9. Name and addresses of witnesses to accident: _________ _________________________________________________________ PROPERTY DAMAGE AND PERSONAL INJURY 10. Property damage (a) Description of property damaged: ____________________ _________________________________________________________ (b) Present location: ___________________________________ (c) Name and address of owner, if other than claimant: __ _________________________________________________________ (d) Nature of damage: ___________________________________ (e) Extent of damage: ___________________________________ 11. Personal injury (a) Nature of injury: ____________________________________ __________________________________________________________ (b) Extent of injury: ____________________________________ __________________________________________________________ INSURANCE COVERAGE 12. Collision insurance (a) Does claimant carry collision insurance? [If yes, answer (b)- (f) below] (b) Name and address of insurer: _________________________ _________________________________________________________ (c) Policy No.: _________________________________________ (d) Has claimant filed claim against insurer in this instance? _________________________________________________________ (e) If claim has been filed, is coverage for full amount of loss? _________________________________________________________ If not full coverage, amount deductible: ________________ _________________________________________________________ (f) If claim has been filed, action taken or proposed to be taken by insurer with respect to claim: _________________________________________________________ 13. Public liability and property damage insurance (a) Does claimant carry public liability and property damage coverage? _________ [If yes, answer (b) below] (b) Name of insurer: ____________________________________ I declare under the penalty of perjury that the amount of this claim covers only damages and injuries caused by the accident described above. I agree to accept that amount in full satisfaction and final settlement of this claim. Dated: __________________________ _______________________________________________ Signature