Make a claim

Person Reporting Claim

First Name

Last Name

Insured Information

First Name

Last Name

Policy number

Address

City/Town

Province

Postal code

Phone Number

Email

Date of Incident

Time of Incident

Incident Location (City)

Incident Location (Province)

Describe what happened

Are you submitting an auto claim?

Yes

Insured Vehicle Information

Vehicle Make, Model, and Year

Plate Number

Vehicle Location

Is it Drivable?

Yes

Details of Damage

Name of Driver

Number of Passengers

Were there any injuries?

Yes

Please detail who was injured and the nature of those injuries

Number of other vehicles involved

Personal

Vehicle

Recreation & Leisure

Commercial

Prize

Learning Centre

Orbit

Legal