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WorldSource International Claims

Highlighted(*) items represent required fields. Please enter 'N/A' if any piece of information is not available and/or local Privacy Laws prohibit disclosure. 

Important Notice:
 This form does not eliminate the contractual requirement under our policy to forward every demand, notice, and/or summons received by the insured or their representative to the insurer. Nor does it eliminate the insured's obligation to comply with any filings required by any state or government agencies.

Commercial Automobile Claim Report Form

 

Basic Claim Details

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Insured Data

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Client Codes:

 
 
 
 

Accident Details

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Insured Vehicle

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Property Damaged

 
 
 
 
 
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Injured Party

 
 
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Adjuster Details

 
 
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