Raphael & Associates Transportation/Auto Claim Form
  • Name*
  • Company Name*
  • Street*
  • City*
  • State*
  • ZIP Code*
  • Phone*
  • Fax*
  • Email*
  • Claim Number*
  • Claims Examiner*
  • Type of Assignment*
  • Date of Loss*
  • Policy Number*
  • Location of Accident*
  • Description of Accident*
  • Were Authorities Contacted?*
  • If so, which authorities were contacted?*
  • Report Number*
  • Violations/Citations*
  • Injuries
  • Any Injuries?*
  • Extent of Injury*
  • Injured Name*
  • Injured Address*
  • Injured Phone Number*
  • Witness
  • Any Witness?*
  • Witness Name*
  • Witness Address*
  • Witness Phone*
  • Additional Comments*
  • Insured
  • Insured Name*
  • Street*
  • City*
  • State*
  • ZIP Code*
  • Home/Cell*
  • Work Phone*
  • Email*can't leave this empty
  • Insured Vehicle
  • Year*
  • Make*
  • Model*
  • VIN*
  • Plate Number*
  • Damage Description*
  • Current Vehicle Location*
  • Owner Name*
  • Owner Address*
  • Owner Phone*
  • Driver Name*
  • Driver Address*
  • Driver Phone*
  • Other Vehicle
  • Year*
  • Make*
  • Model*
  • VIN*
  • Plate Number*
  • Owner Name*
  • Owner Address*
  • Owner Phone*
  • Driver Name*
  • Driver Address*
  • Driver Phone*
  • Damage Description (if applicable)*
  • Additional Comments*
  • Assignment Instructions
  • Statements*
  • Photos*
  • Records & Reports*
  • Police Department*
  • Police Department Phone*
  • Report Number*
  • Other*
  • Records & Reports*
  • Additional Comments*
ABOUT US
Raphael & Associates is a TPA and claims adjusting company internationally recognized for its exceptional service and unsurpassed reputation of nationwide claims handling. We understand the importance of adapting to the demands of a dynamic market and tailor our services to our client's specific needs. Our mission is simple: to provide outstanding service, extraordinary professionals and the best that technology has to offer.

Raphael & Associates

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