MOTOR ACCIDENT CLAIM FORM - Colfire

THIRD PARTY PROPERTY DAMAGE (1) Continued...
Insurer:
THIRD PARTY PROPERTY DAMAGE (2) Continued...
Insurer:
Policy No.:
Policy No.:
Details of Damage:
Details of Damage:
Has any intimation of Claim been made upon you, either verbally or in writing? Yes No
Note:
Any written communication should not be answered and forwarded immediately to COLFIRE. If verbal notice has been received, particulars should
be given above.
9.
ADDITIONAL INFORMATION:
I
the undersigned do hereby authorize COLFIRE to disclose any information in respect of my Claims history to any Investigator, Adjuster, Insurance Company,
Regulatory Body or other Authority, and hereby release COLFIRE from any claims and liabilities of any kind in respect of such disclosure except claims and liabilities
that may arise under this document.
I certify that the foregoing statement is a true account to the best of my knowledge and belief.
Date:
(YYYY-MM-DD)
Insured's Signature
Date:
(YYYY-MM-DD)
Insured's Signature
Any further information which can be given should accompany these particulars.
Please use a blank sheet of paper to provide additional information where space provided is insufficient.
Be sure to attach to the Claim Form.
Download the form and fill it out on your computer.
When you are finished, save the form and submit via email to info@colfire.com
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