Cooper Insurance & Associates
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Certificate of Insurance Request
Report a Claim
Driver Request Form
Request Information

Please fill out the information below in order to report a claim. Feel free to contact us if you
have any questions. Thank you!

*Signifies a required field below

DATE OF ACCIDENT:
APPROXIMATE TIME:
* NAME OF INDIVIDUAL:
(Please use the person filling out this report)
(Please include name and address if different from below)
INSURED INFORMATION
* CONTACT NAME:
D/B/A:
ADDRESS:
Street: City: State: Zip:
* BUSINESS PHONE:
* HOME PHONE:
  EMAIL:
LOSS
ACCIDENT LOCATION: (Please include City and State)
BRIEF DESCIPTION:
AUTHORITY CONTACTED:
REPORT #:
VIOLATIONS/CITATIONS:
INSURED VEHICLES
VEHICLES:
#1:
#2:
Year: Make: VIN#:
 
OWNER'S NAME:
OWNER'S ADDRESS:
Street: City: State: Zip:
(Please provide if unit is an owner operator, or a leased unit)
DRIVER'S NAME:
DOB:
DL #:
STATE:
DESCRIBE DAMAGE:
UNIT LOCATION: (Where can the unit be seen?)
OTHER PROPERTY/CARGO INVOLVED
DESCRIBE DAMAGE:  
(If an auto, please provide Year, Make, Model, Plate # and brief description of damage)
OWNER'S NAME:
OWNER'S ADDRESS:
Street: City: State: Zip:
BUSINESS PHONE:
HOME PHONE:
   
DRIVER'S NAME:
DRIVER'S ADDRESS:
Street: City: State: Zip:
BUSINESS PHONE:
HOME PHONE:
   
UNIT LOCATION: (Where can the vehicle be seen? Name of business/residence)
 
Street: City: State: Zip:
CONTACT NAME:
CONTACT NUMBER:
INJURED
INJURED:
   
NAME #1:
ADDRESS:
Street: City: State: Zip:
INJURY TYPE:
DESCRIBE INJURY:
   
NAME #2:
ADDRESS:
Street: City: State: Zip:
INJURY TYPE:
DESCRIBE INJURY:
   
NAME #3:
ADDRESS:
Street: City: State: Zip:
INJURY TYPE:
DESCRIBE INJURY:
WITNESSESS/PASSENGERS
NAME #1:
ADDRESS:
Street: City: State: Zip:
INJURY TYPE:
Amount: Other:  
 
   
NAME #2:
ADDRESS:
Street: City: State: Zip:
INJURY TYPE:
Amount: Other:  
 
REMARKS
 
 

 

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All rights reserved.
 
810 Rock Quarry Road, Stockbridge, GA 30281 (770)389-0089