Make a claim

Person Reporting Claim

First Name First Name is required

Last Name Last Name is required

Insured Information

First Name First Name is required

Last Name Last Name

Policy number Policy Number is required

Address Address is required

City/Town City is required

Province Province is required

Postal code Postal Code is required

Phone Number

Phone number is required

Email Email is required

Date of Incident Date of Incident is required

Time of Incident Time of Incident is required

Incident Location (City) Incident Location (City) is required

Incident Location (Province) Incident Location (Province) is required

Describe what happened Description is required

Are you submitting an auto claim?

Yes

Insured Vehicle Information

Vehicle Make, Model, and Year Vehicle Make, Model and Year is required

Plate Number Plate Number is required

Vehicle Location Location is required

Is it Drivable?

Yes

Details of Damage Details required

Name of Driver Name is required

Number of Passengers Number of Passengers is required

Were there any injuries?

Yes

Please detail who was injured and the nature of those injuries Details required

Number of other vehicles involved Number of other vehicles involved is required

Personal

Vehicle

Commercial

Learning Centre

Orbit

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