Granada Insurance Company

Contact Information

Policy Holder's Name:
Carrier:
Policy Number:
Primary Contact Phone #:
Secondary Contact Phone #:
Email Address:

Claim Information

Incident Date:
Incident Time:
Location of Incident:
Was anyone injured?	Yes No
Description of Injuries:
Police Dept. Contact:
Investigation Agency Report:
Description of what occurred:
Description of damages:

Damaged Vehicle Info

Were any vehicles damaged?	Yes No
How many vehicles including your own were involved?

Damaged Vehicle 1 Owner

Name:
Address:
City:
State:
Zip:
Phone Number:

Damaged Vehicle 1 Info

Year
Make
Model
VIN #
Location of damaged vehicle?
Phone Number:

Damaged Vehicle 2 Owner

Name:
Address:
City:
State:
Zip:
Phone Number:

Damaged Vehicle 2 Info

Year
Make
Model
VIN #
Location of damaged vehicle?
Phone Number:

Damaged Vehicle 3 Owner

Name:
Address:
City:
State:
Zip:
Phone Number:

Damaged Vehicle 3 Info

Year
Make
Model
VIN #
Location of damaged vehicle?
Phone Number:

Damaged Vehicle 4 Owner

Name:
Address:
City:
State:
Zip:
Phone Number:

Damaged Vehicle 4 Info

Year
Make
Model
VIN #
Location of damaged vehicle?
Phone Number:

Reporting Person's Information

Name of the person
Contact Phone #
Person's Position
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NOTE: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

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