PROPERTY CLAIM

Please fill out the Claim Form completely. Please include all information pertaining to this claim. All fields are required.

This claim form is not an authorization for the repair or replacement of windshields or repairs for any other claimed damages. This claim will not be reviewed unless all appropriate boxes are filled with information relative to the claim. Please note: If a  field doesn't apply to your claim, type N/A in the box. Should you deem your claim repair/replacement costs to be immediate, submit your claim form to Kilgore Claims for liability evaluation and to your own auto/home insurance company for more expeditious handling. Thank you!


Owner / Claimant
Owner's name *
Owner's name
Owner's home phone *
Owner's home phone
Owner's business phone *
Owner's business phone
Owner's cell phone *
Owner's cell phone
Owner's address *
Owner's address
Insurance phone number *
Insurance phone number
Alleged Offending Vehicle
Incident Description
Date of incident *
Date of incident
Time of incident *
Time of incident
$
I understand that this claim form IS NOT AN AUTHORIZATION for the repair or replacement of windshields or repairs for any other claimed damages. Furthermore, this claim will not be reviewed unless all required fields have been completed and appropriate information, relative to the claim, has been provided. *