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Partee Insurance Associates
License #0786033
584 S. Grand Avenue, Covina, CA 91724
Phone: 626-966-1791 Fax: 626-331-8132
Notification of Claim
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In the event of a claim, or even a circumstance which you think could turn into a claim,
please call our office immediately or complete this form and fax it to us and we will
contact you.
Named Insured: ___________________________________________________
Address: ___________________________________________________
___________________________________________________
Phone number: ___________________________________________________
Fax number: ___________________________________________________
Email address: ___________________________________________________
Policy Number: ___________________________________________________
Date and time of loss: ___________________________________________________
Description of loss (specific location, what happened, type and extent of damages, vehicle
and driver involved, etc.):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Other parties involved (name, address, phone number, description of injuries/damages
vehicles & driver involved:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Witnesses (name, address, phone number):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Police or Fire Dept. to which reported including report number:
___________________________________________________________________________________
Person reporting & date: ___________________________________________________________
Reported directly to carrier? _____ If so, when was claim reported? ___________________
Additional Comments:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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