Bermack, Champion & Lewine


This website offers services primarily to current and future residents of NY, CT and NJ.
481 Eighth Avenue, New York NY 10001, Tel. (212) 239-1140

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Auto Claim Form

For existing clients only

Please be as complete as possible, and in addition to completing this form,
please call us at (212) 239-1140 to confirm our receipt and to ask
any questions you may have.

Claimant Information
Name:
Address:
City/State/Zip:	/ /
Phone:
Fax:
Email:
Insurance Company:
Policy #:
Incident Information
Date of Incident:	"mm/dd/yyyy"
Your Vehicle Year and Make:
Name of Driver of Your Vehicle at During Incident:
Above Driver's License #
Name of Driver of Other Vehicle: (if applicable)
Other Driver's License #: (if applicable)
Location of Incident: (Intersection or street, and Town)
Police Contacted: (if yes, please include police force/officer information)
Description of Incident:
Thank You. You have completed the claim form. We will process your claim as quickly as possible. Please do not hesitate to contact us with any questions or comments. Enter any additional comments in the box below, then click the "Submit" button.
Comments

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