Interoffice Claim Form | Jack Bradley Agency

Interoffice Claim Form

Jack Bradley Agency

Claim Form

JBA Staff Member Name ✶

Account Name

Date Agency Notified

Caller's Name

Caller's Phone Number

Is this caller the insured

Yes No

Claim Information

Policy Type

Policy Number

Date of Loss

If Auto Claim

Vehicle Involved

Driver of Insured's Vehicle

Location of Accident

If Property Claim the Location of Loss

Description of Loss

Police Department and Report Number

Other Party Information

Best Way for Adjuster To Reach Insured

Best Person to Talk With

Best Contact Phone Number

Best Contact Email

Claim Reporting

Has claim been reported?

Yes

No I have not reported

Claim Number

Only Complete This Section If the Claim Has Been Reported

Method of Reporting

Adjuster’s Name

Adjusters Phone Number

Any additional Information

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