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Damage Claim Request Form

  1. Instructions

    If this claim is being submitted for damage to a registered vehicle, the owner(s) of the vehicle must be claimant(s). In addition to the Claim Form, please attach photos of road issue, photo of damage to vehicle and any other documents (repair bill/quote). In the case of personal injury, or non-vehicular claims, documentation of losses will be required. All applicable fields on this form must be completed.

  2. Damaged Vehicle Year

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  4. This field is not part of the form submission.