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-- UNITED STATES ONLY --
This is only for accident occurring in the US territory.
Loss Notice
Use this form to report a claim for or with a Qualitas Insurance Company client.
Date reported
*
-
Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Who is reporting?
Please Select
Insured
Claimant
Attorney
Insurance company
Agent/broker/MGA
Name of reporting party:
*
First Name
Last Name
E-mail
*
Phone number of reporting party:
*
-
Area Code
Phone Number
Date of loss
*
-
Month
-
Date
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Insured's policy number
*
Location of loss
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Brief description of accident
*
Police report made?
Yes
No
Please provide details such as Report #, Badge #, etc.
Multiple Accident?
Yes
No
Qualitas Insured information
Insured's name
*
First Name/Company
Last Name
Insured vehicle's VIN number
*
Year
Make
Model
Color
Plates
Vehicle Drivable?
Yes
No
Insured vehicle's driver's name
Injuries?
Yes
No
Please include name and age of injured persons:
Passengers
Yes
No
Passenger Information
Claimant information
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Year
Make
Model
Color
Plates
Vehicle Drivable?
Yes
No
Injuries?
Yes
No
Please include name and age of injured persons:
Claimant's Insurance Carrier
Claimant's policy number
Claimant's claim number
Claimant's adjuster
Want to upload documents?
Yes
No
Photos
Upload a File
Cancel
of
ID/Driver's license
Upload a File
Cancel
of
Policy
Upload a File
Cancel
of
Registration card
Upload a File
Cancel
of
Other Files
Browse Files
Use this option to add any other file relevant to the claim.
Cancel
of
Submit
Print Form
Should be Empty: