EmailMe Form - Claim Loss Report Form

10020 12th Avenue North Battleford, SK S9A 3A4
Toll-Free Phone: 1-866-979-2747
Email: claims@oasisins.ca

Brokerage Information

Broker Name *

Broker Phone Number *

### - ### - ####

Broker Email Address *

Policyholder(s) Information

Policyholder Name(s) *

Policy Number *

Address of Policyholder(s) *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Home Phone Number

### - ### - ####

Cell Phone Number

### - ### - ####

Email of Policyholder

Claim Information

Date of Loss *

DD / MM / YYYY HH : MM AM/PM

Are You Waiting on Any Pending Endorsements from Oasis on This Policy? *

Name of Operator at the Time of the Claim *

Operators Date of Birth *

DD / MM / YYYY

Was Permission Given to the Operator?

Type of Vehicle being Operated

Year *

Make/Model *

Serial Number *

Address of Where the Accident Took Place *

Describe the Accident *

Describe the Damage to the Unit *

Describe Any Injuries and to Whom (List Any Third Parties) *

Have the Police Been Notified?

Police File Number (if applicable)

This Claim is For *

Select all that apply

Third Party's Information

Owner of the Third Party Involved (If applicable)

First Last

Third Party Email

Third Party Phone Number

### - ### - ####

Type of Unit and Details

Terms of Acceptance and Acknowledgment

I, the undersigned, certify that the information provided in this claim loss report form is accurate and truthful. I understand that submitting inflated or fraudulent claims is a serious offense and may result in prosecution. To the best of my knowledge, all statements made in this form are true and correct, and are submitted as a claim under the referenced policy.

I understand that by entering my name below, I acknowledge that this constitutes a legal acknowledgment, confirming that I, the undersigned, agree to and accept the above Terms of Acceptance.

Type Your Name Here *

First Last

Date *

DD / MM / YYYY