NIC

NATIONAL INSURANCE COMPANY

Claims Report - Liability

Loss Report

Claimant:
Name:		Last Name:
Social Security:
E-Mail

E-Mail:

Insured Phones:
						Unit:

Insured Physical Address:

Country:

Zip Code:

Insured Postal Address:

Country:

Zip Code:

Policy Information:
Policy No.:			Certificate:

Policy Effectivity/Expiration Dates and Date of Loss (mm/dd/yy)
Effective Date:
Expiration Date:
Date of Loss:

Loss Information:
Cause of Accident:		Estimated Damages: $

Claimant Information:
Name:		Last Name:		Age:

(If Claimant is a Minor) Provide Full Name of Parent or Tutor:
Name:		Last Name:

Claimant Physical Address:

Country:

Zip Code:

Claimant Postal Address:

Country:

Zip Code:

Claimant Phones:
						Unit:

Description of Accident:

Description of Damages/Injuries :

Additional Information:

Police Complaint No.:
Name of person that reports: