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

Broker's Information

Broker Name *

Broker Phone Number *

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

Broker Email Address *

Confirm Email

Policyholder(s) Information

Policy Number *

Date of Loss *

DD / MM / YYYY HH : MM AM/PM

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

Yes

No

Policyholder(s) *

Address of Policyholder(s) *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email of Policyholder

Confirm Email

Work Phone Number

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

Home Phone Number

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

Cell Phone Number

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

Claim Information

Name of Operator at the Time of the Claim *

Operators Date of Birth *

DD / MM / YYYY

Was Permission Given to the Operator? *

Yes

No

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 police been notified? *

Yes

No

Police Notified At

DD / MM / YYYY HH : MM AM/PM

Police File Number

This Claim Is For *

Physical damage to unit

Liability

Accident benefits for operator

Select all that apply

Third Party's Information

Owner of the Third Party Involved

First Last

Driver (If Different from the Owner)

First Last

Address of the Third Party Involved

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Plate Number

Insurers

Policy 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. *

I agree

I disagree

Type Your Name Here *

First Last

Date *

DD / MM / YYYY