LaRueClassics.com

Claims Form

  In the event of a claim, use this form to initiate the process.

This form has 6 parts:
          1. Owner / Insured Information
          2. Vehicle Information
          3. Driver Information
          4. Accident Information
          5. Loss Information
          6. Police Information

* fields are required. Any other information that you don't
   know or don't have readily available can be left blank.
  

Owner / Insured Information (Part 1 of 6)

  Policy Number:    
  Name: *  
  E-mail:
 *  
  Address: *  
  City, State: *  
  Zip: *  
  Home Phone: *  
  Work Phone:    
  Cell Phone:    
  Best Time To Call:     Morning      Afternoon       Evening

Vehicle Information (Part 2 of 6)

  Year (4 digits - ex: 1960): *  
  Make:
 *  
  Model: *  
  Vehicle Identification Number 
(VIN):		 *  
  Where is the vehicle now?    
  Was it towed?     Yes    No
  If yes, who towed it?
(Company, Address, Phone)		    
  Amount of tow fee:    
  Describe damage to vehicle: *  

Driver Information (Part 3 of 6)

  Driver Name and Address:
(Check here if same
as owner)		    
  Driver Phone Numbers:
(Check here if same
as owner) 		   
  Marital Status:    
  Date of Birth (mm/dd/yyyy):    
  Relationship to  
Owner / Insured: 		   
  Driver's License Number:    
  State of Issue:    
  Expiration Date (mm/dd/yyyy):    
  Restrictions on License:    
  What citations, if any, 
were issued to the driver?		    
  Vehicle used with  
owner's permission? 		    Yes    No

Accident Information (Part 4 of 6)

  Date of Accident (mm/dd/yyyy): *  
  Time of Accident:    
  Location of Accident:
(Street Names, City, State 		   
  Purpose of Trip:
(To/From)		    
  Describe Accident: *  

Loss Information (Part 5 of 6)

  How many other vehicles and/or properties were damaged? (Do not include your vehicle.)
Please enter a number from 0 to 10		 *  
  How many injuries were there? (Your vehicle and others involved)
Please enter a number from 0 to 10		 *  
  How many witnesses or passengers were involved? (Your vehicle and others involved)
Please enter a number from 0 to 10		 *  

Police Information (Part 6 of 6)

  Police contacted:     Yes    No
  Police Report filed:     Yes    No
  If yes, Police Report number:    
  Officer's name and/or badge number:    
  What police or fire department responded?    
  Police Department Phone Number: