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Policy Number:
Your Name:
Contact Person:
Whom should the adjuster contact about repairs?
Name:
Home phone:
Work phone:
Email address:
Authority Contacted:
Police department:
Report number:
Claim Information:
Date of loss:
Location of claim:
Cause of loss:
Collision
Fire
Glass breakage
Theft
Vandalism
Wind Damage
Other-describe below
Describe, if other cause of loss:
Your Damaged Car:
Year/Make/Model:
Driver's name/address:
Driver's phone number:
Describe your damage:
Where is your car now?
Persons Injured:
Name and address:
Phone number:
Nature of Injuries:
Describe Other Car:
Year/Make/Model:
Owner's name/address:
Owner's PH#
Driver's name/address:
Driver's phone number:
Describe damage:
Insurance agent/company:
Describe What Occurred:
Comments and/or Other Information
Harris Insurance Inc.
335 Frankfort Road
Shelbyville, KY 40065
Telephone:
(502) 633-2212
Fax:
(502) 633-2217
E-mail Us
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