FILE A CLAIM

Any party filing a claim against any member of our Self-Insurance Pool, must fill out the claim form below and shall also Email info@AnpcMutual.org with the following:

1. Accident Report

2. Photos of the Damages incurred

3. Quote from a reputable repair shop showing the monetary amount of damages you are claiming.

Accident Claim Form

CLAIMANT INFORMATION

Claimant Full Name

Claimant Full Address

Claimant Email

Claimant Phone Number

Claimant Insurance Policy Number

POLICY HOLDER INFORMATION

Policy Number

Policy Holder Name

Policy Holder Address

ACCIDENT INFORMATION

Accident Date

Were Police/Fire Contacted? Required

Yes

Accident Time

Accident Location

If Yes, Police/Fire Report Number

Did any Injuries result from Accident? Required

Yes

If Yes, List Individuals Name, Address, Ph# and Extent of Injuries

Was your automobile damaged? Required

Yes

If Yes, What type of Damage?

Automobile Year

Make

Model

Where can the damaged car be seen?

Other type of Property Damage? If yes, Please explain

*ACCIDENT INFORMATION. Please add clear Description of accident facts.

Successfully submitted. We’ll get back to you soon.

ANPC Mutual

A Trust Pool of Bonded Self Insured Charitable Outreach Ministries

FILE A CLAIM

Accident Claim Form