Cooper Insurance & Associates
Back to Home
About Us Get a Quote forms Links Request Information Contact Us
 
What changes are made to your policy once the regulatory filings for your authority are issued?
Contact Us
Click here if you
have questions
or need to
contact us!
Forms
Get a Quote
Certificate of Insurance Request
Report a Claim
Driver Request Form
Request Information

Please fill out the information below in order to report a claim. Feel free to contact us if you
have any questions. Thank you!

*Signifies a required field below
DATE OF ACCIDENT:
APPROXIMATE TIME:
*NAME OF INDIVIDUAL:
(Please use the person filling out this report)
(Please include name and address if different from below)
INSURED INFORMATION
*CONTACT NAME:
D/B/A:
ADDRESS:
Street: City: State: Zip:
*BUSINESS PHONE:
*HOME PHONE:
EMAIL:
LOSS
ACCIDENT LOCATION: (Please include City and State)
BRIEF DESCIPTION:
AUTHORITY CONTACTED:
REPORT #:
VIOLATIONS/CITATIONS:
INSURED VEHICLES
VEHICLES:
#1:
#2:
Year: Make: VIN#:
 
OWNER'S NAME:
OWNER'S ADDRESS:
Street: City: State: Zip:
(Please provide if unit is an owner operator, or a leased unit)
DRIVER'S NAME:
DOB:
DL #:
STATE:
DESCRIBE DAMAGE:
UNIT LOCATION: (Where can the unit be seen?)
OTHER PROPERTY/CARGO INVOLVED
DESCRIBE DAMAGE:
(If an auto, please provide Year, Make, Model, Plate # and brief description of damage)
OWNER'S NAME:
OWNER'S ADDRESS:
Street: City: State: Zip:
BUSINESS PHONE:
HOME PHONE:
   
DRIVER'S NAME:
DRIVER'S ADDRESS:
Street: City: State: Zip:
BUSINESS PHONE:
HOME PHONE:
   
UNIT LOCATION: (Where can the vehicle be seen? Name of business/residence)
 
Street: City: State: Zip:
CONTACT NAME:
CONTACT NUMBER:
INJURED
INJURED:
   
NAME #1:
ADDRESS:
Street: City: State: Zip:
INJURY TYPE:
DESCRIBE INJURY:
   
NAME #2:
ADDRESS:
Street: City: State: Zip:
INJURY TYPE:
DESCRIBE INJURY:
   
NAME #3:
ADDRESS:
Street: City: State: Zip:
INJURY TYPE:
DESCRIBE INJURY:
WITNESSESS/PASSENGERS
NAME #1:
ADDRESS:
Street: City: State: Zip:
INJURY TYPE:
Amount: Other:  
 
   
NAME #2:
ADDRESS:
Street: City: State: Zip:
INJURY TYPE:
Amount: Other:  
 
REMARKS
 

 
© 2008. DreamEFFEX, LLC.
All rights reserved.		  
810 Rock Quarry Road, Stockbridge, GA 30281 (770)389-0089