¨-Required information

Basic Information
¨Policyholder:  
¨Email Address:     ¨ Phone Number:
  Policy Number, if known:
¨Date of Claim Occurrence (MM/DD/YY):
  Time of Occurrence:   AM/PM AM PM

  You are filing this claim as an insured or claimant?: Insured Claimant (not insured by us)   

¨Location of Claim:

¨ Description of Incident:



¨Were the Police or Fire Department called? Yes/No Yes No    
Department Contacted (e.g. Marion County Sheriff, Greenwood FD)
Report Number:

Vehicle Information (Please complete as much as possible)
Your vehicle:
Year: 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 or before   Make: Model: 
VIN (Serial No.):
Driver's Name: Date of Birth:
Address:  Telephone Number:
Driver's License Number:    License State: IN AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL KS KY LA MA MD ME MI MN MO MS MT NC NH ND NE NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY       
Describe damage to vehicle:
Where is vehicle?
Insurance on this vehicle: Select I am insured with Jensen Insurance Other insurance provider No Insurance
If not insured with Jensen Insurance, what is the name of your insurance company?    Policy Number:
Do you have a repair estimate? Yes/No Yes No      How much is the estimate?
If you have a fax machine, please fax the estimate to 317-888-8897.

Other Vehicle (Please use addition comments if more than 2 vehicles were involved
Year: 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 or before   Make: Model: 
VIN (Serial No.):
Driver's Name: Date of Birth:
Address:  Telephone Number:
Driver's License Number:    License State: IN AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL KS KY LA MA MD ME MI MN MO MS MT NC NH ND NE NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY       
Describe damage to vehicle:
Where is vehicle?
Insurance on this vehicle: Select I am insured with Jensen Insurance Other insurance provider No Insurance
If not insured with Jensen Insurance, what is the name of your insurance company?    Policy Number:

Additional Comments: