Whims Insurance - Report a Loss


	Report a Loss

Call (248) 651-7321 8:30 a.m. to 5:30 p.m. EST to speak to a member of our licensed & accredited staff

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To help us serve you better, please complete all required information (indicated by an asterisk ( * ) and/or highlighted in light blue).

*Name of Insured:

Date and Time of Loss

* Today's Date:
* Date of Loss:
Time of Loss:	AM PM

Person Reporting Claim

* Name:
* Phone:
Email:

Agencies Involved

Police Report Number (if applicable):
Fire Dept Report Num. (if applicable):
Other agencies or comments:

Location and Description of Loss

* Location of Loss :

* Description of Loss :

If there is no more relevant information forward to submit button, otherwise continue with the rest of the form

If Person Injured

Injured Name :

Injured Phone:

Injured Address:	Extent of Injury:

If Property Damaged

Describe Property and Location
(house, building, fence, auto, etc.):

Property Owner's Name :

Property Owner's Phone:

Estimated amount to repair::

Property Owner's Address :	Describe Damage to Property :

If property is a vehicle,
where can it be seen:

If Vehicle Caused Damage

Vehicle Year: Make: Model: License Plate Num:

Owner's Name : Owner's Phone:

Vehicle Owner's Address:

Driver's Name : Driver's Phone:

Driver's Address:

Driver's Relationship to Insured : Vehicle used with permission?: YES NO

Driver's Date of Birth : Driver's License Number: State Issued:

Purpose of Use:	Violations or Citations Issued:

Any other pertinent information:

Form Submission Agreement:
I agree that by submitting this form the questions were answered to the best of my ability.
I am authorizing Whims Insurance to act upon the information given.

Please check if you agree to these terms:

If you entered a valid email address, you will receive a computer generated confirmation that the form has been sent. We will personally send you an email confirmation once we have received and evaluated your loss to ensure it qualifies as a claim under your insurance policy.