Claim Reporting Instructions

1. Items with * must be completed. Please complete as much of the questionnaire as possible. Upon completion, please click the blue SUBMIT button .
2. Leave the information you do not have blank.
3. Send any additional information or documents related.
4. Fax or email additional pages (if applicable) to 714-546-4457 or Claims@RSI-Ins.com. Please use a cover page and put attention Claims Dept.

AUTO LOSS CLAIMS FORM

Your Name *

Email Address *

Your Phone Number *

Are you the ... *

RSI Client
Claimant/Other Party

Business Name of the RSI Insured

Policy #

Date of Accident *

Approximate Time

Location of Accident (i.e. Street, Address, Freeway, or Intersection)

City

State

Please provide us with a brief description of the accident

Police Name

Department Phone #

Report #

Our Insured Vehicle Information

Year

Make

Model

Last 6# of Vehicle Identification

Your Vehicle Damage

Physical Damage Claim?

Yes
No

Our Insured Driver Information

Name

License #

Date of Birth

Phone

Address

Claimant/Other Party Information or Property Owner

Name

License #

Phone

Plate

Address

Insurance Company

Policy #

Year

Make

Model

Describe Vehicle or Property Damage

Injuries? (Names and Phone #)

Please provide us with the name(s)of any witnesses or passengers. Names and phone numbers are required.

Any Damage to Cargo?

Any Damage to Containers/Trailers/Chassis?