Car Claim
  1. Car Claim
  2. First Name
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  3. Last Name
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  4. Address
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  5. City
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  6. Province
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  7. Postal Code
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  8. How would you like us to contact you?
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  9. Daytime Phone
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  10. Night-time Phone
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  11. Best Time To Call
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  12. Email Address
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  13. Number of vehicles you want to claim
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  14. Date of Loss
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  15. Time of Loss
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  16. Location of Accident or Claim
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  17. Cause of Accident or Claim
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  18. Description of Accident or Claim
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  19. Description of Any Injuries. Include name of injured
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  20. Authority Contacted
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  21. Report Number
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  22. Citations Issued
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  23. Vehicle Involved
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  24. Person Driving
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  25. Witness's or Passenger's Name
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  26. Other Driver's Name
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  27. Other Driver's Address
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  28. Other Driver's Insurance Company
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  29. Other Driver's Policy Number
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  30. Please give any additional comments you feel appropriate. If you have additional information
    where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.
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  32. First Name
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  33. Last Name
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  34. Current Email Address
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  35. Submit This Form
      
 

DeHart & Stauffer Insurance Brokers Copyright © 2014. All rights reserved.
843 King Street WestOshawa, Ontario L1J 2L4 (905) 576-2234Fax 1-253-550-4655