Claim Notification

Notification of Claim

Automobile Claim

	Type of Claim:
	Name:
	Address:
	Policy Number:
	Policy Effective Date:
	E-mail:
	Agency:
	Agent:
	Residence Phone:
	Mobile Phone:
	Business Phone:

	Automobile Claim
	Date of the Accident:
	Time:
	Exact Address of the Accident:
	Describe in Detail the accident:
	Insured Vehicle:
	Make:
	Model:
	Vehicle Identification (Motor/Serial) Number:
	License Plate/Tag Number:
	Name, age and address of the driver:
	Damage to the Insured unit:
	Estimate of Repairs:

	Injured Party/Parties: Include name, age and address of each party. Indicate the nature of the injuries,where they received medical attention and if they were hospitalized:
	Injured Parties:	Name: Age: Address: Injuries: Lesiones:
	Damage to Property of Other:
	Name:
	Age:
	Address:
	Damage:

	Witnesses
	Name:
	Address:

	Police Complaint
	Was a complaint filed?
	Complaint Number:
	Address of Police Station receiving Report:
	Action against the parties taken by the authorities:
	Third Party Insurers:
	Policy Number(s):
	Additional Information:

Real Legacy Assurance Company, Inc.
P.O.Box 71467 San Juan, P.R. 00936-8567	Metro Office Park Calle 1 Lote 4 Guaynabo, P.R. 00968

Subsidiary of