Claim Manager

Griffin Accident Information Form
Time of Your Accident/Loss*

: HH

MM
Date of Your Accident/Loss*
Please List Your Insurance Carrier
What Type of Accident Or Loss Was Incurred*
- Homeowner Claim
- Auto Claim/Loss
- Other
Has this claim been directly reported to your insurance company?*
- Yes
- No
- Don't Know
Enter Additional Information Below
Policy #
Name*
First Last
Email*
Phone #
Describe the accident or loss in detail.

Griffin Accident Information Form