REPORT OF LOSS
Canal Insurance Company
P.O. Box 7
Greenville, SC 29602
Reported Fri Sep 5 16:20:17 2008

Fields with blue boxes are required.

Name:
Address
Phone
Email Address (a copy of the form will be emailed to this address)

Date:
Time
Location
Reported to Police? :
 yes no
Name of Responding Department:


Name:
Address
Phone
Liability Policy Number
Physical Damage Policy Number
Cargo Policy Number

Name:
Address:
Phone:


Same as Policyholder
Same as Driver
Other (enter below)
Name of Owner, if Other:

Year, Make, Model:
Vehicle Identification Number:
Damage to Vehicle:
Is Vehicle Driveable / Operational? :
 yes
no
unknown
Current Location of Vehicle:
Location Phone if Available:

Year, Make, Model:
Vehicle Identification Number:
Damage to Insured Vehicle:
Is Vehicle Driveable/Operational? :
 yes
no
unknown
Current Location of Insured Vehicle:
Location Phone if Available:


Name:
Address:
Phone:
Name:
Address:
Phone:

Year, Make, Model:
Vehicle Identification Number:
Damage to Claimant Vehicle:
Is Vehicle Driveable / Operational? :
 yes
no
unknown
Current Location of Claimant Vehicle:
Location Phone if Available:

Name:
Phone Number:
Claims #:






yes:
no:
unknown:

Name:
Address:
Phone:

Name:
Address:
Phone:


Assured backed into claimant
Assured changed lanes
Assured hit parked vehicle
Assured overturned
Assured rear-ended claimant
Disputed liability
Fuel spill
Jackknife
Right turn squeeze
Windsheild
Assured hit animal
Other - enter below

Send additional copy of form to this email address: