Staebler Insurance Brokers - Tools & Resources

The Best Insurance Is An Insurance Broker

Online Claim Reports - Notice of Auto Claim

In an emergency claim situation, please contact our office directly at (519) 743-5221 or 1-800-321-9187. After business hours, please contact our Ultimate Claims Service at 1-888-STAEBLR (782-3257).

Please take your time filling out this form. You will be given an opportunity to check for errors. Note that items marked with an asterisk are required.

Policy Holder Information

Policy Number:*

Primary Contact Person:*

Home Phone:*

Work Phone:

Where should we contact you?

Best time to contact you?

Accident Information

Who was driving?

Date of Loss or Accident:

Time of Accident:

Vehicle Year (yyyy):

Vehicle Make:

Vehicle Model:

Is the vehicle drivable?

Yes

If no, where can the vehicle be inspected?

Please provide as much detail as possible regarding the claim in the spece provided below.
A reporesentative will contact you shortly.
(Max 255 Words)

Did any injuries result from the Accident?

Yes

If yes, please provide names, addresses, phone numbers and the extent of the injuries.
(Max 255 Words)

Other Driver Information

Full Name:

Insurance Provider:

Policy Number:

Contact Phone:*

Licence Plate #:

Vehicle Year (yyyy):

Vehicle Make:

Vehicle Model:

Location of Accident

City / Province:

Police Contacted?*

Yes

Officer's Name:

Officer's Badge Number:

Report Number:

Were there witnesses?*

Yes

Witness #1

First Name:

Last Name:

Contact Phone:

Work Phone:

Email Address:

Name of your broker:

Disclaimer:

H.L. Staebler Company Limited is not responsible for instructions not received and acknowledged by a confirmation via e-mail or phone call. By submitting this form, you acknowledge that you are the policyholder and the events described on this form are truthful. Only the person named as the insured in the policy documents can submit a claim report on this policy. All policy terms and conditions apply, subject to policy status at time of submission.