EmailMe Form - Got Toys? Loss Report Form

10020 12th Avenue, North Battleford, SK S9A 3A4
Toll free: 1-866-979-2747 Fax 1-866-488-6122
email - claims@oasisins.ca

Your Broker: *

Broker Phone # *

### - ### - ####

Broker Email Address: *

Confirm Email

Policy Number *

Date of Loss *

DD / MM / YYYY HH : MM AM/PM

Are you waiting on any pending endorsements from Oasis on this policy? *

Yes

No

Policy Holder: *

Address of Policy Holder: *

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

Email of Policy Holder:

Confirm Email

Work Phone #

### - ### - ####

Home Phone #

### - ### - ####

Cell Phone #

### - ### - ####

Date of Birth of Operator *

DD / MM / YYYY

Name of operator: *

Permission Given to Operator? *

Yes

No

Vehicle being operated: *

Year: *

Make/model: *

Serial Number: *

Accident Location: *

Describe the accident: *

Describe the damage to the unit: *

Describe any injuries and to whom (list any third parties): *

Other Party Involved:

	Name
Owner of 3rd Party Involved
Driver (if different from owner)

Address of Third Party Involved:

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

Plate Number:

Insurers:

Policy Number:

Type of Unit and Details:

Have police been notified? *

Yes

No

Police Notified At:

DD / MM / YYYY HH : MM AM/PM

Occurrence Number:

Charges Laid:

Yes

No

If yes, charges were laid against who?

Insured

Third Party

Give names and addresses of witnesses:

This claim is for: *

Physical damage to unit

Liability

Accident benefits for operator

Select all that apply

Terms of Acceptance and Signature.

I, the named insured, for this claims loss report, warrant the truthfulness of the information provided in this form. I understand that inflated or fraudulent claims is an offense and will be prosecuted. The foregoing statements are true and correct to the best of my knowledge, and are submitted as a claim under the above referenced policy.

I understand that checking this box constitutes a legal signature confirming that I, the named insured, acknowledge and agree to the above Terms of Acceptance. *

I agree

I disagree

Signature: *

Clear

Signature of broker if information was taken verbally.

Name: *

First Last

Date: *

DD / MM / YYYY