Carolina Insurance Services, Inc.

Form Under Construction

Claim Identification Information

Company
Insurance Company Name
Policy Number

Insured
Name of Insured (as shown on policy)
Telephone Number of Insured

Whom should claims investigator contact about this report
Name
Address
Phone Number
When to Contact

Person making this report (If other than contact person)
Name
Phone Number

Details of Loss
Loss Resulting from Accident
Location of Accident
Street Address
City
State

Date of Accident
Time of Accident

Was this loss previously reported
Has suit been filed (If suit has been filed, it is CRITICAL that suit papers IMMEDIATELY be faxed to CAROLINA INSURANCE SERVICE -- 336.721-1667)

Name of Police Authority Contacted
Any Citations issued?
Who Citation was issued to:

Description of accident
Persons Injured
Names of Persons Injured in Accident
Addresses of those persons
Phone numbers of those persons
For each person listed, was that person a pedestrian, driver or passenger in insured vehicle, driver or passenger of claimant vehicle, passenger of claimant vehicle or other Extent of injuries of each person listed

Insured vehicle in accident
Year, make and model
Vehicle Identification Number (VIN)
Drivers name
Drivers address
Phone number
Where is insurers vehicle now
Describe damage to insured vehicle

Other vehicles in accident (if any)
Describe year, make and model of other vehicles
Name of drivers of other vehicles
Names of insurers of other vehicles
Describe damage to other vehicles

Witnesses not listed above
Name(s)
Address(s)
Phone numbers(s) where can be contacted

Other remarks