C L Butcher Agency
P.O. Box 5449
Knoxville, TN 37928
(865) 689-5482
Fax: (865) 689-5491

Auto Loss Claim Form

Please be as thorough as you can be with the information you are about to provide. The more we get .. the quicker and more accurately we can move forward to assist you with your claim ... Thanks!

* Required Fields

Name:
Your Company Name:
Address / City / State / Zip:
Home Phone:
Office Phone:
Mobile Phone:
*Email Address:
Accident / Loss Information
Date and Time of Accident:
Location of Accident (incl. City):
Authority to which reported:
Police Report Number:
Violations / Citations:
Thoroughly Describe your Accident:
Insured Vehicle
Year:
Make:
Model:
Driver Name of Insured Vehicle:
Relationship to Owner:
Used with Permission:
Other Parties Property Damage
Please be as thorough as you can describing every little detail plus describe, as best you can, any damage to the other parties vehicle below.:
Other Parties Name and Address
Address / City / State / Zip:
Other Parties Home Phone:
Other Parties Work Phone:
Other Parties Mobile Phone:
Injuries?
Inured Person:	Pedestrian Driver Passenger
Person Injured Name:
Address / City / State / Zip:
Injured Parties Home Phone:
Injured Parties Work Phone:
Injured Parties Mobile Phone:
Injured #2 Information
Inured Person:	Pedestrian Driver Passenger
Person Injured Name:
Address / City / State / Zip:
Injured Parties Home Phone:
Injured Parties Work Phone:
Injured Parties Mobile Phone:
Please give us any other information that we might need that would help to process your Claim more accurately.:
*This report was completed by:
Please click the Send button only once.