Auto Claim

Your Wawanesa Insurance policy number is required to complete this claim form.

Asterisks indicates a required field

There are errors in the form

Reporter Information

Who is reporting the claim?

Wawanesa Insured Broker

First name

Last name

Reporters Contact Information: Please type at least one phone number below

Home phone number

Business phone number

Extension

Cell phone number

Email address

Insurance company name

Insurance company policy #

Loss Information

Wawanesa policy number

Your policy number, last name or company name can be found in the top left corner of your policy documents or invoice.

Need more help?

Date of loss

Time of loss

Street/Freeway location

City

Country

Canada United States of America

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Describe the accident or incident

Other Party Information

First name

Last name

Address

City

Country

Canada United States of America

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

Home phone number

Business phone number

Extension

Cell phone number

Date of birth

Drivers license number

Injuries

Other Party Vehicle Information

Vehicle year

Vehicle make

Vehicle model

Vehicle color

License plate

VIN

Vehicle damages

Wawanesa Insured Information

Is the insured the same person reporting the claim?

First name

Last name

Address

City

Country

Canada United States of America

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

Home phone number

Business phone number

Extension

Cell phone number

Driver Information

Is the driver of the insured vehicle same as above?

Yes No No Driver Unknown

---

Date of birth

Drivers license number

Describe any injuries suffered

Driver of the Insured Vehicle

First name

Last name

Address

City

Country

Canada United States of America

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

Home phone number

Business phone number

Extension

Cell phone number

Date of birth

Drivers license number

Describe any injuries suffered

Wawanesa Insured Vehicle

Vehicle year

Vehicle make

Vehicle model

Vehicle color

License plate

VIN

Vehicle damages

Police Report

Was a police report or joint report obtained?

Police Report Joint Report No Report

---

Police force that report was obtained from:

Your police report number:

Other Parties

Are there additional other parties not reported above?

Yes No

Solo Vehicle Loss - No Other Party Involved

How many other parties?

1 2 3 4 5

Other Party 1

The insured vehicle was struck by an unknown party

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Insurance company name

Insurance company policy #

Date of birth

Drivers license number

Describe any injuries suffered

Other Party 1 Vehicle Information

Vehicle year

Vehicle make

Vehicle model

Vehicle color

License plate

VIN

Vehicle damages

Other Party 2

The insured vehicle was struck by an unknown party

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Insurance company name

Insurance company policy #

Date of birth

Drivers license number

Describe any injuries suffered

Other Party 2 Vehicle Information

Vehicle year

Vehicle make

Vehicle model

Vehicle color

License plate

VIN

Vehicle damages

Other Party 3

The insured vehicle was struck by an unknown party

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Insurance company name

Insurance company policy #

Date of birth

Drivers license number

Describe any injuries suffered

Other Party 3 Vehicle Information

Vehicle year

Vehicle make

Vehicle model

Vehicle color

License plate

VIN

Vehicle damages

Other Party 4

The insured vehicle was struck by an unknown party

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Insurance company name

Insurance company policy #

Date of birth

Drivers license number

Describe any injuries suffered

Other Party 4 Vehicle Information

Vehicle year

Vehicle make

Vehicle model

Vehicle color

License plate

VIN

Vehicle damages

Other Party 5

The insured vehicle was struck by an unknown party

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Insurance company name

Insurance company policy #

Date of birth

Drivers license number

Describe any injuries suffered

Other Party 5 Vehicle Information

Vehicle year

Vehicle make

Vehicle model

Vehicle color

License plate

VIN

Vehicle damages

Passengers / Witnesses

Were there any passengers in any of the involved vehicles?

Yes No

No passengers in any involved vehicles

How many passengers?

1 2 3 4 5

Passenger 1 Information

Location of passenger

Select

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Date of birth

Drivers license number

Describe any injuries suffered

Passenger 2 Information

Location of passenger

Select

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Date of birth

Drivers license number

Describe any injuries suffered

Passenger 3 Information

Location of passenger

Select

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Date of birth

Drivers license number

Describe any injuries suffered

Passenger 4 Information

Location of passenger

Select

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Date of birth

Drivers license number

Describe any injuries suffered

Passenger 5 Information

Location of passenger

Select

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Date of birth

Drivers license number

Describe any injuries suffered

Were there any witnesses?

Yes No

No Witness

How many witnesses?

1 2 3 4 5

Witness 1 Information

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Date of birth

Drivers license number

Describe any injuries suffered

Witness 2 Information

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Date of birth

Drivers license number

Describe any injuries suffered

Witness 3 Information

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Date of birth

Drivers license number

Describe any injuries suffered

Witness 4 Information

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Date of birth

Drivers license number

Describe any injuries suffered

Witness 5 Information

First name

Last name

Address

City

Country

Canada United States of America

Province

Select One Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal code

State

Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Home phone number

Business phone number

Extension

Cell phone number

Date of birth

Drivers license number

Describe any injuries suffered

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