Geico Claim Report Printable Form PDF Details

You can find more info relating to the geico claim report printable form by looking through the table our team compiled.

QuestionAnswer
Form NameGeico Claim Report Printable Form
Form Length3 pages
Fillable?Yes
Fillable fields102
Avg. time to fill out21 min 13 sec
Other namesgeico total loss power of attorney form, geico claim, gieco claims, geico claim forms

Form Preview Example

Instructions

The Accident Report is for you to document what happened. Please include the name of GEICO insured, your claim number, and complete details related to the accident, then sign and date the form.

(Form Below)

GOVERNMENT EMPLOYEES INSURANCE COMPANIES

 

 

 

 

GEICO INSURED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REPORT OF ACCIDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GEICO CLAIM #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YOUR NAME

 

 

 

 

 

 

 

 

 

AGE

 

 

 

 

 

 

OCCUPATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

(NUMBER)

 

(STREET)

(CITY)

(STATE) (ZIP)

 

PHONE NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS OF EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BUSINESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ARE YOU MARRIED? IF YES, G I V E FULL NAME OF SPOUSE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAKE OF OUR INSURED”S

 

YEAR

 

 

MODEL

 

 

 

LIC NO

 

 

STATE

 

AUTO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS OF OUR INSURED DRIVER

 

 

 

 

 

 

 

 

 

 

 

DRIVER”S LICENSE #

 

 

 

 

AGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHAT COMPANY(S) INSURES

 

NAME OF COMPANY (S)

 

 

POLICY NO.

 

DOES THE POLICY CONTAIN

YOUR AUTOMOBILE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL COVERAGE FOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL EXPENSES?

 

 

 

 

 

 

 

PHONE #

 

 

 

 

 

CLAIM #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

DATE OF

 

 

 

 

TIME

PLACE OF ACCIDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCIDENT

 

 

 

 

M.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAKE OF YOUR AUTO

 

 

 

YEAR

 

MODEL

 

 

 

LIC. NO.

 

 

 

 

 

 

 

 

 

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OF REGISTERED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OWNER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS OF DRIVER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER'S LICENSE #

 

AGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WAS DRIVER ON

 

 

 

 

 

IF YES, FOR WHAT PURPOSE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ERRAND FOR OWNER?

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME, ADDRESS, AND TELEPHONE NUMBER OF OCCUPANTS OF YOUR AUTOMOBILE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WERE YOU HURT? YES

 

NO

WAS ANYONE HURT? YES

NO IF SO, G I V E NAME, ADDRESS AND TEL. NO. OF OTHER PERSONS INJURED:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEAT BELTS

 

NAME

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

TEL. NO.

 

 

 

IN USE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATURE OF YOUR INJURIES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS OF DOCTOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAMES AND ADDRESSES OF ALL WITNESSES (OTHER THAN OCCUPANTS OF YOUR CAR):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF AFTER DARK, WERE ALL VEHICLES LIGHTED?

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONDITION OF ROAD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WEATHER CONDITONS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(PLEASE COMPLETE OTHER SIDE)

C-22-OR 02-06) NS

STATE FULL DETAILS OF HOW THE ACCIDENT HAPPENED:

WHERE CAN CAR BE SEEN DURING THE DAY?

LIST THE AREAS OF YOUR CAR WHICH WERE DAMAGED IN THE ACCIDENT:

DESCRIBE DAMAGED PROPERTY OTHER THAN YOUR AUTO

ARE YOU MAKING A CLAIM?

AGAINST WHOM?

 

 

 

 

 

FOR WHAT AMOUNT?

 

 

YES

 

NO

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DID YOU REPORT THE ACCIDENT TO

WHERE? (DEPT. ADDRESS)

 

 

 

 

 

 

POLICE?

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WAS ANYONE CHARGED?

WHO

 

 

 

 

CHARGES

 

 

YES

 

NO

 

 

 

 

 

 

 

 

DRAW A SKETCH OF THE ACCIDENT USING THIS DIAGRAM:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Show by arrow in this

 

 

 

 

 

 

 

 

 

 

circle which way is

 

 

 

 

 

 

 

 

 

North.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please label autos, stop

 

 

 

 

 

 

 

 

 

 

 

signs, traffic signals,

 

 

 

 

 

 

 

 

objects, street names, etc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law

C-22-OR 02-06) NS

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Write the significant details in NAME, ADDRESS, YES, CORNS, PLEASECOMPLETEOTHERSIDE, and WEATHERCONDITONS area.

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