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Automobile Claim Form
Notice of Automobile Loss
Insured Name:
*
Insured Address:
*
Date of Incident:
*
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Time of Incident:
*
Location of Incident:
*
Authority Report to:
*
Case Number:
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Were there any arrests?
*
Yes
No
Who was arrested?
*
Were any tickets issued?
*
Yes
No
Who was ticketed and what was the charge?
*
Description of Occurrence:
*
Please upload any other documents such as police reports, lawsuits, receipts, photos etc…
1. File Upload
2. File Upload
Attach a maximum of 10 files to each file upload field. A zip file containing multiple files counts as 1.
If you are having any issues uploading certain files above, please email your documents to:
claims@ib-tx.com
Damage to Your property
Vehicle Year:
*
Make:
*
Model:
*
Vehicle Identification Number (VIN)
*
Driver's Name:
*
Driver's Phone Number:
*
Driver's Date of Birth:
*
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License State:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
License Number:
*
Damage to the Vehicle:
*
Is the vehicle drivable?
*
Yes
No
Property Damage to Others
Was there another vehicle damaged?
*
Yes
No
Vehicle Year:
Make:
Model:
Vehicle Identification Number:
Driver's Name:
Driver's Phone Number:
Driver's Date of Birth:
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License State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
License Number:
Damage to the Vehicle:
Is the vehicle drivable?
Yes
No
Injuries
Was anyone injured?
*
Yes
No
How many people were injured?
*
1
2
3
1. Name:
Address:
Phone Number:
Whose vehicle were they in?
What seat were they in?
Driver
Passenger
Backseat
Extent of Injures:
2. Name:
Address:
Phone Number:
Whose vehicle were they in?
What seat were they in?
Driver
Passenger
Backseat
Extent of Injures:
3. Name:
Address:
Phone Number:
Whose vehicle were they in?
What seat were they in?
Driver
Passenger
Backseat
Extent of Injures:
Witnesses
Were there any witnesses?
*
Yes
No
Name:
Address:
Phone Number:
Whose vehicle were they in?
Name:
Address:
Phone Number:
Whose vehicle were they in?
Contact Information
Contact Name:
*
Contact Email:
*
Contact Phone Number:
*
Additional Information: