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Report A Claim

Your Information
Policyholder Name:
E-mail Address:
Policy Number:
   

Loss Information
Type of claim:
Date of Occurrence:
Where did it happen:
Was a police report taken?
Police department.
Report number:
Details of  loss (What happened):
   

Your vehicle
Year, Make, Model:
Driver of your vehicle (if any):
Was a child seat in your vehicle?
Was a child in it at the time?
Did your air bags deploy?
Is your vehicle driveable?
If no, location of your vehicle:
Phone number where your vehicle is:
   

Other Party's Vehicle

Other Party Vehicle #2

Other Party Vehicle #3
Year, Make, Model: Year, Make, Model: Year, Make, Model:
Driver of this vehicle (if any): Driver of this vehicle (if any): Driver of this vehicle (if any):
Was a child seat in this vehicle? Was a child seat in this vehicle? Was a child seat in this vehicle?
Was a child in it at the time? Was a child in it at the time? Was a child in it at the time?
Did this vehicle's air bags deploy? Did this vehicle's air bags deploy? Did this vehicle's air bags deploy?
Is this vehicle driveable? Is this vehicle driveable? Is this vehicle driveable?
If no, location of this vehicle: If no, location of this vehicle, if known: If no, location of this vehicle, if known:
Phone number where this vehicle is: Phone number where this vehicle is: Phone number where this vehicle is:

If additional vehicles were involved, scroll to the right to enter information.

Injuries
Name of injured person:
Vehicle this person was in:
Phone number for injured person:
Name of injured person:
Vehicle this person was in:
Phone number for injured person:
Name of injured person:
Vehicle this person was in:
Phone number for injured person:

Witnesses
(not in an involved vehicle)
Name of witness #1:
Phone number for this witness:
Name of witness #2:
Phone number for this witness:
Name of witness #3:
Phone number for this witness:

 

 

Kennedy Professional Insurance Agency
P.O. Box 847
19167 Highway 18, Suite 1
Apple Valley, CA  92307
(760) 242-2345 Phone
(760) 242-2211 Fax
kpia@kpia.com
License#:  0B44021
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