MOTOMAXX POLICY INFORMATION

Date of Loss *		Policy # *
First Name *		Last Name *
Address
City		Prov/Postal
Phone # *		Email
Prefer Contact Method	By PhoneBy Email	Type of Claim *	Total LossPartial LossDeductible Reimbursement
Vehicle Info *	Year: Make: Model:

PRIMARY INSURANCE CLAIM INFORMATION

Insurance Company *		Claim Number *
Adjuster		Repairer Info

OTHER INFORMATION

Brief Description of Incident