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 firstname.lastname@example.org. 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) Next 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) Previous Next 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 Previous Next Gain Insured Driver Information Company Name Driver Name Driver License Number Address City State Zipcode Previous Next 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 Previous 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 email@example.com 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.