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Claim Reporter Contact Information

Name:

Which of these are you?

Please enter at least one phone number:

Home Phone	(please include area code)
Work Phone	(please include area code)
Cell Phone	(please include area code)

Email:

Contact Preference:

Wilson Mutual Policyholder Information

Policy Number:

Agent Name:

Policyholder Name:

Street:

City:

State:

Zip:

County:

Please enter at least one phone number:

Home Phone:	(please include area code)
Work Phone:	(please include area code)
Cell Phone:	(please include area code)

Email:

Contact Preference:

Contact Name:

(Person we can contact regarding this claim)

Loss Information

Date of Loss:	mmddyyyy
Time of Loss:
Location of Loss:(include city and state)

Description of Loss & Damage:

What Authority Was at the Scene?
Name of Police/Fire Dept:
Report Number:

Injured or Damaged Party/Other Party Property Damage (not the policyholder)

Other Party's Name, Address, and Phone

Name:
Street:
City:
State:	Zip:
Home Phone:	(please include area code)
Work Phone:	(please include area code)
Cell Phone:	(please include area code)
Email:
Contact Preference:

Other Party Injury/Damage Info

Were there any injuries? Yes No

Were there any witnesses? Yes No

Additional Comments:

FRAUD WARNING

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

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