Claim Form Step 1 of 6 16% Date of Incident(Required) MM slash DD slash YYYY Day of Week(Required)SundayMondayTuesdayWednesdayThursdayFridaySaturdayTime of Incident(Required) Hours : Minutes AM PM AM/PM ClaimantName(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Owner (if different from claimant)Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneEmail Place of Injury or DamageYour Direction of Travel(Required)Highway, Street, or Road(Required)County or Nearest Town(Required)Nature of Damage(Required)Amount of Claim (2 Estimates)(Required) Your VehicleYear(Required)Color(Required)Make(Required)Model(Required)RK Hall Vehicle (If Any)ColorTypeUnit or License Plate #Trailer ColorTypeUnit or License Plate # Event DetailsDescription and Cause of Event(Required)Name and Address of Any Witness to the Above IncidentWas This Event Reported to a Law Enforcement Agency?(Required) Yes No If Yes, Which Agency?(Required)Has a Claim Been Made for This Event With Your Insurance Carrier?(Required) Yes No If Yes, Name and Address of Insurance Agent(Required) AffidavitState of(Required)County of(Required)Claimant's Name(Required)Day(Required)Month(Required)Year(Required)Signature of Claimant(Required)Signature of Notary(Required)
