Automobile Claim

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WHAT IS YOUR RELATIONSHIP TO ONESOURCE CMS?(Required)

POLICY NUMBER(Required)

DATE OF LOSS(Required)

MM slash DD slash YYYY

TIME OF LOSS(Required)

Hours

:

Minutes

AM/PM

INSURED INFORMATION

YOUR ROLE(Required)

BUSINESS NAME OR INDIVIDUAL(Required)

BUSINESS

INDIVIDUAL

NAME(Required)

First Last

BUSINESS NAME(Required)

CONTACT INFO

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

HOME PHONE(Required)

Email

MOBILE PHONE(Required)

WORK EXT

INSURED DRIVER INFORMATION

SAME AS INSURED?

YES

NO

Name(Required)

DRIVER FIRST NAME DRIVER LAST NAME

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

HOME PHONE

MOBILE PHONE

WORK EXT

Email

CAR SEAT PRESENT

YES

NO

CAR SEAT OCCUPIED(Required)

YES

NO

PASSENGER IN VEHICLE

YES

NO

NUMBER OF PASSENGERS

INSURED PASSENGER INFO

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

HOME PHONE

MOBILE PHONE

WORK EXT

EMAIL

WAS THERE INJURY

YES

NO

INJURY DESCRIPTION

LOSS INFORMATION

TYPE OF LOSS

LOSS DESCRIPTION(Required)

NUMBER OF VEHICLES INVOLVED

AUTHORITIES CALLED

YES

NO

Report Number

INSURED VEHICLE INFORMATION

MAKE

YEAR

MODEL

VEHICLE LOCATION

IS VEHICLE DRIVEABLE

YES

NO

CLAIMANT INFORMATION

YOUR ROLE

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

HOME PHONE

MOBILE PHONE

WORK EXT

EMAIL

IS SAME AS INSURED

YES

NO

Name

DRIVER FIRST NAME DRIVER LAST NAME

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

MOBILE PHONE

HOME PHONE

WORK EXT

EMAIL

CAR SEAT PRESENT

YES

NO

CAR SEAT OCCUPIED(Required)

YES

NO

PASSENGER IN VEHICLE

YES

NO

NUMBER OF PASSENGERS

CLAIMANT PASSENGER INFO

NAME

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

HOME PHONE

MOBILE PHONE

EMAIL

WORK EXT

WAS THERE INJURY

YES

NO

INJURY DESCRIPTION

CLAIMANT VEHICLE INFORMATION

MAKE

YEAR

MODAL

VEHICLE LOCATION

IS VEHICLE DRIVEABLE

YES

NO

WITNESS INFORMATION

IS THERE A WITNESS(Required)

YES

NO

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

HOME PHONE

MOBILE PHONE

EMAIL

WORK EXT

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

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HEADQUARTERS
OneSource Claims Management, LLC
6320 Canoga Avenue, Suite 750
Woodland Hills, CA 91367
(877) 467-4262
Claims fax number: (818) 449-9099
Claims email address:
claims@onesourcecms.com

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File a Claim

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Name

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Email

Subject

Message

Name

This field is for validation purposes and should be left unchanged.

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