Claim Report - Gain Insurance

Claim Reporting Instructions 1. Items with * must be completed. Please complete as much of the questionnaire as possible. Upon completion, please click the SUBMIT button . 2. Leave the information you do not have blank. 3. Attach any additional information or documents related on the last page before you submit. 4. If you have any question please contact our Claims Department at 323-987-2333 x 4 or claims@gainins.com. 5. You may call and follow up with our Claims Department once you have submitted your claim.

First Name (required)

Last Name (required)

Email (required)

Phone (required)

Accident Information

Applicant Role (required)
Claimant (Damaged/Injured Party)Gain Insurance ClientThird Party

Accident Date (Required)

Accident Time (required)

Accident Location: (required)

Accident City: (required)

Accident State: (required)

Accident Description: (required)

Authorities/Law Agency (Police): (required)

Authorities/Law Agency Phone #(Police): (required)

Case #: (required)

Gain Insured Vehicle Information

Year

Make

Model

Full VIN

Insured Vehicle Damage

Any damage to the vehicle that a claim will be made for?
YesNo

Gain Insured Driver Information

Company Name

Driver Name

Driver License Number

Address

City

State

Zipcode

Non-Gain Driver Information

First Name

Last Name

License Number

Plate Number

Phone Number

Address

City

State

Zipcode

Insurance Company

Policy Number

Vehicle Year

Vehicle Make

Vehicle Model

Property/Vehicle Damage Description

Injuries

Witnesses/Passengers

Damage To Cargo

Damage To Trailer(s), Container(s), Chassis?

Attach Any Additional Documents

As the Internet is not a fully secure environment, Gain Insurance Agency cannot ensure that this or any other email has not been interfered with during transmission. The sender, therefore, does not accept liability for any errors or omissions in the contents of this message that arise because of email transmission.

Acknowledge

“Please keep in mind that this acknowledgment does not constitute acceptance of coverage, change, endorsement or an agreement to insure, and does not create any obligation of any kind, contractual or otherwise. Changes and payments to policies are not effective or binding until you, or any party involved, receive official acceptance notice from either your insurance agent, or your insurance company in writing via email.”

If you have any questions regarding your email please call our contact office directly

Gain Insurance Agency

323-987-2333 x 1 Customer service

service@gainins.com