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Change Your TOIRMA Contact Person
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Claim Form
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County
Phone
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Fax
Contact Name
Position
Email
Date of accident/incident
Time of Accident/Incident
Location of Accident/Incident
Description of Accident/Incident
Name of state agency/authorities responded
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What type of claim?
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Auto
Inland Marine
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LIST YEAR/MAKE/MODEL/VIN#
Cause & Description of Damage
Township Driver Information
Complete this section if accident/incident involved another party:
Township Driver's name
Phone
Seat belt?
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Yes
No
List passengers in Township vehicle
List any injuries
Citations issued?
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Other Party's Information
Name
Phone
Address
Year, Make & Model
List any injuries
Citations issued?
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No
Drivable?
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Yes
No
Description of damage
Passenger(s) Names/Phone#s
Witness Information
Name & Phone#s
Additional Information
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Report Completed By
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Title
Phone