Auto Loss Report.

After you have submitted your claim online you’ll receive an email confirmation and we will respond by the next business day. If your policy needs to be changed or there are any injuries as a result of the accident you’re reporting, please call us right away at 1-800-387-2656.

Policy Holder Information

* Inditcates mandatory field

First Name *

Last Name *

Postal Code * (Format: L#L #L#)

Suite, unit, P.O Box

Street Number *

Street Name *

City *

Province *

Province

Phone Number * (Format: ###-###-####)

Cell Phone (Format: ###-###-####)

Policy Number * (A-)

Loss Information

Describe What Happened * (If you or your passengers are injured, we strongly recommend that you call us immediately at 1-800-387-3656)

Location of Accident

Date Of Loss * (Format: MM/DD/YYYY)

Time (Format: HH:MM)

Street 1

Street 2

City *

Province *

Province

Police Force

Officer Name

Badge #

Your Vehicle Information

Year *

Year

Car Make *

Car Model *

Current Location

Driver Information

First Name *

Last Name *

Phone Number * (Format: ###-###-####)

Injured? *

Injured

Injury Description

Passenger Information

Passenger's Full Name

Passenger's Phone (Format: ###-###-####)

Injured?

Injured

Injury Description

Other Vehicle Involved

Year

Car Make

Car Model

Other Involved Driver / Pedestrian

Full Name

Phone Number (Format: ###-###-####)

Insurer

Policy Number

Injured?

Injured

Injury Description

Other Involved Passenger

Other Passenger's Full Name

Other Passenger's Phone (Format: ###-###-####)

Injured?

Injured

Witness

Witness' Full Name

Witness' Phone (Format: ###-###-####)

Additional Information

Any Additional Information

Identity of Submitter

First Name *

Last Name *

Phone Number * (Format: ###-###-####)

Email Address (Format: name@url.com)

By clicking submit, you agree that the foregoing statement is correct and accurate and you understand that we will establish a claim file in order to assign resources to respond to your needs.