Colton, Downey & Associates, Inc.


	1122 Veterans Drive, Jacksonville, IL 62650 217-243-8484 FAX 217-243-3301 109 Morse, Roodhouse, IL 62082 217-589-5890 FAX 217-589-4925

Home, Auto, Boat, Mobilehome, Motorcycle, Rental Dwelling, and more.

As Business Grows, and You Start To Have Insurance Woes, Call The Pros

24 Hour Claim Services

COMMERCIAL INCIDENT/ACCIDENT CLAIM FORM

Fill out the form online below with information relating to your claim: (Some lines may not be related to your claim)


Your Company Name:
Today's Date:
Person Completing this report:

Type of Incident
Injury to Person:
Damage to Company Property:
Damage to Other's Property:
Date of Incident:	A.M. P.M.
Location of Accident/Incident:

Police or Fire Dept. Called:
What Happened:

What Was The Cause:

Other Party's Information
Name:
Address and Phone Number:
Injuries
Any Injury?	Y N
Describe Injury:


We will be in contact with you on the next business day.


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