Hyannis Office 88 Falmouth Rd. * Hyannis, MA 02601 Tel. 508.775.6060 * Fax 508.790.1414
South Dennis Office 485 Rte. 134 * PO Box 1497 * S. Dennis, MA 02660 Tel. 508.398.6060 * Fax 508.394.2267
2. Address
3. Mail Address if different
7. Email
8. Home Phone
9. Work Phone / Ext.:
10. Fax
11. Best Time To Contact mornings afternoons evenings
About the Claim
12. Date Accident Occurred (02/22/99)
13. Location of the Claim: 13a. City 13b. Street
14. Did the Police or Fire Departments Respond to the Accident? Yes No
15. If Yes to Number 14, What Police and Fire Departments? (List Town)
16. What Kind of Loss Did You Experience? wind water fire theft other
16a. If You Answered "other" to number 16, please list
17. Please Describe the Problem or Incident
Personal Injury
18. Was anyone injured? List Name
18a. Their Address
18b. Their Phone Number
19. Describe the Injuries Sustained
20. Questions and/or Comments