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Create a Claim Report - Automobile

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


If this is a claim emergency, please call 1-844-WAWANESA (929-2637). We're available 24/7.

* indicates a required field


    Your Information

    First Name*
    Last Name*
    Please type at least one phone number below *
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Email Address
    Insurance Company Name
    Insurance Company Policy #

    Loss Information

    Our Policy Number* Help
    Date of Loss*
    (mm/dd/yyyy)
    Time of Loss* :
    Street/Freeway Location*
    City*
    Country
    State*
    Province*

    Describe the Accident or Incident*


    Other Party Information

    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Other Party Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages

    Our Insured Information

    Same as Your Information
    First Name*
    Last Name*
    Address
    City
    Country
    Province*
    Postal Code
    State
    Zip Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Is The Driver Of The Insured Vehicle Same As Above?

    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Driver Of The Insured Vehicle

    First Name*
    Last Name*
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Our Insured Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages

    Police Report

    Was a police report or joint report obtained?


    Other Parties

    Are there additional Other Parties not reported above?*


    How Many?

    Solo Vehicle Loss - No Other Party Involved


    Other Party 1 Information

    Our Insured Vehicle Struck By Unknown Party
    First Name*
    Last Name*
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Insurance Company
    Insurance Policy number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Other Party 1 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages


    Other Party 2 Information

    Our Insured Vehicle Struck By Unknown Party
    First Name*
    Last Name*
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Insurance Company
    Insurance Policy number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Other Party 2 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages


    Other Party 3 Information

    Our Insured Vehicle Struck By Unknown Party
    First Name*
    Last Name*
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Insurance Company
    Insurance Policy number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Other Party 3 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages


    Other Party 4 Information

    Our Insured Vehicle Struck By Unknown Party
    First Name*
    Last Name*
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Insurance Company
    Insurance Policy number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    Other Party 4 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN

    Vehicle Damages


    Other Party 5 Information

    Our Insured Vehicle Struck By Unknown Party
    First Name*
    Last Name*
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.
    Cell Phone Number
    Insurance Company
    Insurance Policy number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries

    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?*


    How Many?  
    No passengers in any involved vehicles


    Passenger 1 Information

    Location Of Passenger
    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Passenger 2 Information

    Location Of Passenger
    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Passenger 3 Information

    Location Of Passenger
    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Passenger 4 Information

    Location Of Passenger
    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Passenger 5 Information

    Location Of Passenger
    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Were there any witnesses?*


    How Many?  
    No Witness


    Witness 1 Information

    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Witness 2 Information

    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Witness 3 Information

    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Witness 4 Information

    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries


    Witness 5 Information

    First Name
    Last Name
    Address
    City
    Country
    State
    Zip Code
    Province
    Postal Code
    Home Phone Number
    Business Phone Number ext.<
    Cell Phone Number
    Date of Birth (mm/dd/yyyy)
    Drivers License Number

    Injuries




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