1-888-933-WAWA (9292)

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Create a Claim Report - Automobile

Our insured's policy number is required to report a claim on line.
If you do not have our insured's policy number available to you or in the case of an emergency, please call your service office.
(This website based reporting site is monitored during normal business hours).

Greater Montreal:514-342-2211
Elsewhere in Quebec:Our service offices
Toll free:1-888-933-WAWA (1-888-933-9292)

For after hours CLAIM EMERGENCY, please contact 1-855-801-0297

* 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
    Company Name
    File Number
    Insurance Company Name
    Insurance Company Policy #

    Loss Information

    Our Policy Number* ANC
    Date of Loss* (mm/dd/yyyy)
    Time of Loss* :
    Street/Freeway Location*
    City*
    Country
    State*
    Province*
    Describe the Accident or Incident*
    (Limited to 25 lines)

    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
    Please type at least one phone number below*
    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

    Our insured vehicle was struck by an 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 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN
    Vehicle Damages

    Other Party 2

    Our insured vehicle was struck by an 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 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN
    Vehicle Damages

    Other Party 3

    Our insured vehicle was struck by an 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 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN
    Vehicle Damages

    Other Party 4

    Our insured vehicle was struck by an 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 Vehicle Information

    Vehicle Year
    Vehicle Make
    Vehicle Model
    Vehicle Color
    License Plate
    VIN
    Vehicle Damages

    Other Party 5

    Our insured vehicle was struck by an 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 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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    Verification Code




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