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Complete the following contact information.
Texas Colonial Policy Prefix:    
Texas Colonial Policy Number:
First name:  
Last name:  
Address:  
Apt:
City:  
State:  
Zip Code:  
Driver License Number:
Drivers licence issuing state:
Home phone: ( ) - (xxx)-xxx-xxxxx  
Work Phone: ( ) - (xxx)-xxx-xxxxx  
Cell Phone #1: ( ) - (xxx)-xxx-xxxxx
Email address:
I am reporting the claim as:
Complete the following information about your vehicle
Make:
Model:
Year: (yyyy)
Color:
License number:
State:
Was the vehicle towed?
If Yes, where was it towed to?
Was the airbag deployed:
General area of damage:
Complete the following information about the other vehicle
Other driver's insurance company:
Other driver's policy number:
Make:
Model:
Year: (yyyy)
Color:
License number:
State:
General area of damage:
Vehicle is currently located at:
Location name (Garage, body shop, or towing company lot):
Address:
City:
State:
Contact name:
Phone Number:
Accident information
Describe what happened:
City: (Where the accident took place):
State: (Where the accident took place):
Was the police called?
Was anyone injured?
Injured individual
Located at when injured
First Name
Last Name
Address
City
State
Zip
Phone
Injury Description
Birth Date
Age
Social Security Number
Taken by ambulance?
2865

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