subject_line
Commercial Auto Claim Reporting Form
KMRD Client Contact Information
First Name
*
🛈
Last Name
*
🛈
Company Name of KMRD Client
*
🛈
Phone:
*
Email:
KMRD Service Person Name Or Office
🛈
Driver Information
(if different than above)
First Name
🛈
Last Name
🛈
Phone:
Email:
Supervisor Information
Direct Supervisors First Name
🛈
Direct Supervisor's Last Name
🛈
Auto Information
Year
*
Make:
*
Model:
*
Vehicle Identification Number (Only last 4 digits are required)
Is this vehicle equipped with any aftermarket special equipment?
*
Yes
No
General Questions
Date of Accident
*
+
Time of Accident
*
Location of Accident (include nearest cross street, city & state)
*
Describe the Accident
*
Upload a drawing of the accident if possible
Upload photograph 1 if available
Upload photograph 2 if available
Upload photograph 3 if available
Upload photograph 4 if available
Traffic Conditions
Weather & Road Conditions
Speed of Car Just Before Accident
Did the Car Skid?
Yes
No
How many feet?
Did the Other Car Skid?
Yes
No
How many feet?
Place of impact on Company’s vehicle / estimated damage
Any other conditions that may have caused the accident
Was an ambulance on the scene?
*
Yes
No
If yes, describe who and to what extent were the injuries?
Other Driver's Information
First Name
🛈
Last Name
🛈
Phone
Drivers License #
State
Year
Make
Model
Color
Place of impact on other car / estimated damage:
Insurance Company of Other Vehicle
Agent Name
Policy Number
Yes
No
Did the Other Driver Appear to have been drinking?
Any statement made by the other driver as to the cause of the accident?
Police Officer Information
First Name
🛈
Last Name
🛈
Badge Number
Barracks / County
Incident Report # (if applicable)
Witness Information
First Name
🛈
Last Name
🛈
Phone
First Name
🛈
Last Name
🛈
Phone
First Name
🛈
Last Name
🛈
Phone
First Name
🛈
Last Name
🛈
Phone
Thank you for utilizing this system. You should recieve confirmation of your request via email. A KMRD representative will reach out to you with questions if we have them. If you do not hear from us, feel free to call at
866-957-KMRD (5673)
or
contactus@kmrdpartners.com
This form is for communication purposes only. This form does not bind coverage.