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Personal
Auto Insurance
Home & Property Coverage
Homeowner Insurance
Condo Insurance
Renter & Tenant Insurance
Business
Edmonton Business Insurance
Professional Services Insurance
Trades & Industrial Insurance
Retail & Service Industry Insurance
Claims
Claims
Report a Claim
24/7 Emergency Claim Contacts
About
About Us
Careers
Our Partners
Blog
Contact
Contact Us
Edmonton South Branch (Windermere)
Edmonton North Branch
Get a Quote
Claim Report – Auto
This form will allow you to report a claim to our brokerage. You may save and continue later if necessary.
Your Information
Are you currently insured with our brokerage?
Yes - I am a client of the brokerage
No - I am a third party filing a claim against a client of the brokerage
Name
First
Last
Primary phone number
*
Secondary phone number
Email
Address
*
Street Address
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Your policy info
Policy number
*
Insurance carrier
*
Please Choose
Aviva Insurance Co.
Economical Insurance Co.
Intact Insurance Co.
Nordic Insurance Co.
Optimum West Insurance Co.
Peace Hills Insurance Co.
Royal and Sun Alliance Facility
Wawanesa Mutual Insurance Co.
Other - not listed
Please type in the name of your insurance carrier
*
Please enter Year, Make and Model of your vehicle
*
Please enter the VIN (serial number) of your vehicle
Other driver(s) policy info
Tip: You may skip and leave fields blank if you don't have all the information at hand.
Were there other vehicles involved in the incident?
No
1 other vehicle
2 other vehicles
3 other vehicles
Details for other vehicle #1
Please fill out any details you have for the other drivers.
Year, Make and Model of vehicle
*
VIN (serial number) of vehicle
Name of driver
First
Last
Please enter any contact info you have for the driver
Is this driver also the listed owner on the vehicle's insurance slip and registration?
Yes
No
Name of registered owner of vehicle
First
Last
Please enter any contact info you have for the owner
Name of insurance company
Insurance policy number
License plate number
Details for other vehicle #2
Please fill out any details you have for the other drivers.
Year, Make and Model of vehicle
*
VIN (serial number) of vehicle
Name of driver
First
Last
Please enter any contact info you have for the driver
Is this driver also the listed owner on the vehicle's insurance slip and registration?
Yes
No
Name of registered owner of vehicle
First
Last
Please enter any contact info you have for the owner
Name of insurance company
Insurance policy number
License plate number
Details for other vehicle #3
Please fill out any details you have for the other drivers.
Year, Make and Model of vehicle
*
VIN (serial number) of vehicle
Name of driver
First
Last
Please enter any contact info you have for the driver
Is this driver also the listed owner on the vehicle's insurance slip and registration?
Yes
No
Name of registered owner of vehicle
First
Last
Please enter any contact info you have for the owner
Name of insurance company
Insurance policy number
License plate number
Loss Information
When did the loss occur?
*
YYYY dash MM dash DD
What time did the loss occur?
Please describe the incident, including WHERE it occurred and WHAT exactly happened
If there were any passengers or witnesses, please provide contact information for them
If you have filed a Police Report, please provide the police report number as well as the police force that the report was obtained from
Upload photos or documents
Drop files here or
Select files
Accepted file types: pdf, jpg, gif, png, Max. file size: 2 MB, Max. files: 10.
Please upload any files you feel are relevant (pictures, police report, etc.). Maximum 10 files, up to 2MB each.
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