Form 1190F
© 2003 Nationwide Publishing Company, Inc.
http://www.claimspages.com
DRIVER’S STATEMENT
Driver’s Name: Owner’s Name:
Driver’s Address: City: State: Age:
Phone Nbr: Driver’s License Nbr: State: EXP: //
Employed By: Address of Employer:
What was the vehicle being used for at time of accident?
Date of Accident:... | | Similar to Automobile Accident Report (1160F), this form is given to claimants to capture the details of an accident. Includes damages, occupants and witnesses. |
Report form that is given to vehicle owners and drivers to capture the details of an accident. Includes occupants, injuries, damages and witnesses. | | A sworn statement by a policyholder on an automobile claim. Filled out and notarized, this is a formal request by the insured for payment from the insurance company. |
Used to determine a vehicle's value after a total loss by considering the book value and local market value (dealer quotes). | | A loss report form filled out by insureds and/or agents when reporting an automobile accident. Includes information on occupants, injuries, damages and witnesses. |
Form 1120F
© 2003 Nationwide Publishing Company, Inc.
http://www.claimspages.com
Claim Number
Policy Number
VEHICLE REPAIR ORDER
I hereby authorize
as my chosen repair facility to repair my vehicle, which is described below, and in accordance with the
estimate which was prepared by the repair facility.
Year:
Make:
Model:... | | Automobile Loss Notice (Acord) |
| | Form 1110F
© 2003 Nationwide Publishing Company, Inc.
http://www.claimspages.com
SWORN STATEMENT IN PROOF OF LOSS (AUTOMOBILE)
POLICY NUMBER CLAIM NUMBER
to
POLICY PERIOD INSURANCE COMPANY NAME
By the above numbered policy of insurance, you insured
(hereafter called the Insured) against damage or loss of to the automobile... |
Form 1100F
© 2003 Nationwide Publishing Company, Inc.
http://www.claimspages.com
PASSENGER’S STATEMENT
Name: Address:
Occupation: Employed by:
Age: Driving Experience:
Date of accident: Hour Day or night?
Location of accident:
Vehicle Year, Make, and Model (that you were in):
Was the vehicle in good operating order at... | | Form 1090F
© 2003 Nationwide Publishing Company, Inc.
http://www.claimspages.com
VEHICLE INSPECTION REPORT
Claim Number Agency
Date of Accident Policy Number
To:
On , 20, I personally examined the vehicle below which was
involved in an accident on . Identification and examination was
made at .
Owner:
Owner Address:
Year:... |
Form 1070F
© 2003 Nationwide Publishing Company, Inc.
http://www.claimspages.com
NOTICE OF SUBROGATION RIGHTS
Claim Number:
On , you or your vehicle was involved in an
accident with, our policyholder.
We have settled with our policyholder and now look to you for reimbursement of
$.
If you were covered by insurance, merely complete... | | Form 1060F
© 2003 Nationwide Publishing Company, Inc.
http://www.claimspages.com
RELEASE AND TRUST AGREEMENT
Uninsured / Underinsured Motorist Coverage
PROPERTY DAMAGE ONLY
I/we, for the sole consideration of
dollars ($) to be paid by
, hereinafter called
the Company, the undersigned in his/her/their capacity as insured(s), and/or... |
Create your own time line using this Microsoft Excel template. Just enter dates and labels. | | A release form signed by an insured when making an uninsured motorist or underinsured motorist claim. Requires the insured to cooperate in the recovery of funds from the responsible party. |
Used as a general release form which is signed by insureds and specifies the payments that are authorized to be issued. | | Acknowledgment by the current owner that his vehicle has been declared a total loss, and that he/she has elected to retain the salvage for a specific sum of monies. Towing and storage charges are also specified. |
