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Liability Claim Report

DO NOT ADMIT FAULT, LEAVE THE SCENE OR DISCUSS WITH ANYONE EXCEPT POLICE. CALL POLICE AND COMPLETE THE FOLLOWING INFORMATION:

* Denotes a mandatory fields (n/a if not available)

1. Policy Details
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2. Insured Details
3. Police Fire Dept Information
4. Owner Information
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5. Injured
6. Witness Detail
7. Adjuster Details
All losses should be reported directly to: Joel Carey of Partners Indemnity Brokers.

Business No.: (905) 336-1302
Mobile No.: (905) 876-6411
Facsimile: (905) 681-1054
E-mail: jcarey@csrm.ca