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)Color Type Unit or License Plate # Trailer Color Type Unit 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)
