Current Form: PIRMA Member Property or Casualty Claim

PIRMA Member Information

Member Name:

PIRMA Agreement No:

Member Address:

Member Contact Name:

Member Contact Phone No:

Member Contact Email Address:

Name/Positions of Person Submitting Claim:

Loss Information

Date of Loss: :

Location of Loss:

Description of Incident:

If Member Vehicle is involved, list vehicle (Year/Make/Model/Last 5 digits of the VIN) and driver:

Loss Reported to Authorities:
Yes No

Authority Contacted:
Police Department
Fire Department

Claimant/Damage Information

Type of Claim:
Damage to Member Auto/Property Only
Damage/Injury to another Person/Property (Claimant) Only
Damage/Injury to Both Member Auto/Property and Claimant Person/Property

Describe Member Damages (if applicable):

Claimant / Injured Party Name (if applicable):

Claimant Address :

Claimant Phone No:

Any Bodily Injuries to Claimant?:
Yes No

Any Property Damage to Claimant?:
Yes No

Describe Injuries and Damages to Claimant:

Were Any Additional Parties (other than listed above) Injured/Damaged?
Yes No
If yes, please provide information for other parties :


Any Witnesses of the Loss:
Yes No

Witness Name:

Witness Address:

Witness Phone No:

Be sure to provide ALL CONTACT INFORMATION BEFORE hitting the submit button below. If the form is submitted without proper contact information, we will not be able to get in touch with you. Please double check all fields.