Harco National Insurance Company

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Contact Harco Today

1-800-448-4642

Report a Claim

REPORT DATE:

Wednesday, February 22, 2012

Reported by (First and Last Name)

Reported to (First and Last Name)

Accident Date

Accident Time

Phone Number

Fax Number

Email Address

Policy number

Effective date

Expiration date

INSURED

NAME AND ADDRESS

Name:

Address:

City:

State:

Zip:

Contact (first and last name)

Contact email (If different than Reported Email)

Phone number

Fax number

LOSS

Accident address

Address:

City:

State:

Zip:

Authority contacted

Report number

Tickets issued

Insured driver Other driver

Accident description

INSURED VEHICLE

VEHICLE INFORMATION ON TRACTOR & TRAILER

Vehicle #	Year	Make/model	Plate number	State	VIN #

Owner's name & address

Name:

Address:

City:

State:

Zip:

Owner's primary phone

Owner's alternate phone

Driver's name & address

Name:

Address:

City:

State:

Zip:

Driver's primary phone

Driver's alternate phone

Driver's relation to insured

Driver's job title

Driver's date of birth

Drivers license number

D.L. State

Describe the damage

Estimate amount $

When and where can the vehicle be seen?

OTHER PARTY

Describe the damaged property (If auto, year, make, model, plates, etc.)

INSURANCE COMPANY OR AGENT INFORMATION

Insurance company name

Policy or claim number

Owner's name & address

Name:

Address:

City:

State:

Zip:

Owner's primary phone

Owner's alternate phone

Driver's name & address

Name:

Address:

City:

State:

Zip:

Driver's primary phone

Driver's alternate phone

Describe the damage

Estimate amount $

When and where can the vehicle be seen?

INJURED

Name & address	Phone number	Insured vehicle or pedestrian	Age	Extent of injury
		Insured Vehicle Other Vehicle Pedestrian
		Insured Vehicle Other Vehicle Pedestrian
		Insured Vehicle Other Vehicle Pedestrian

WITNESSES OR PASSENGERS

Witness or Passenger	Name & address	Phone number	Insured vehicle or pedestrian
WP			Insured Vehicle Other Vehicle Pedestrian
WP			Insured Vehicle Other Vehicle Pedestrian
WP			Insured Vehicle Other Vehicle Pedestrian

REMARKS

Send me a copy of my emailed information.