Hamilton Risk Management

Claims First Report

If you have an accident, use this form to record the facts. Include the names and address of all parties involved, and any witnesses to the accident. Thank you.

*Denotes required fields


*Name:		*Phone:	(e.g. 444-444-4444)	*Email:	(e.g. tom@yourisp.com)

Policy#:		*Primary Phone:	(e.g. 444-444-4444)
*Name:		Secondary Phone:
*Address:
*City:	State:
Zip Code:

Loss Date:	(e.g. mm/dd/yy)	Loss Time:	(e.g. 12:00 AM)
Case#		Authority Contacted:	YesNo
Violations/Citations:		Accident Location:
*Accident Description:

VIN#:		*Year:
*Make:		*Model:
Tag:		Vehicle Location:
Is vehicle drivable?	YesNo	State:
*Describe Damage:
Was vehicle towed:	YesNo	Tow Company:
Tow Company #:

License #:		*Primary Phone:
Name:		Secondary Phone:
Address:		Email:
City:	State:	Was anyone injured?	YesNo
Zip Code:		Witness:	YesNo