Enter First and Last name of the Amistad Insurance Policy Holder:
Enter policy number and name of the insurance company:
Date of Loss:
Time of Loss:
Brief Description of What Happened:
Was anyone injured in this loss:
If anyone was injured, please list the name or names below:
Did an ambulance go to the scene of the accident?:
Was anyone transported to the hospital?:
If yes, please write down the name of the person or persons who were transported.
What vehicle was involved in the loss:
What side of the vehicle was damaged
(Front, Rear, Driver's side Front, Driver's side rear, Passenger's side Front, Passengers side rear):
Name of the person reporting the loss:
Name of the person driving, at the time of the loss:
Was there a police report:
Street and City where the accident occurred:
Named insured address:
List all contact telephone numbers:
Select ALL That Apply
My vehicle was damaged or stolen.
Someone else's vehicle was damaged.
Someone in my vehicle was injured.
Someone in another vehicle was injured.
A pedestrian was injured.
OPTIONAL: Comments/Uploads (Photos, Police Report, etc.)