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Village of Bensenville Claim Form

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Steps

1. Section 1: Must be completed by all claimants This section is complete This section is incomplete
2. Section 2: Claims Concerning Vehicle Damage or Automobile Accident This section is complete This section is incomplete
3. Section 3: For Claims Concerning Personal Injury This section is complete This section is incomplete
4. Section 4: Claims Concerning Property Damage Other Than Automobile This section is complete This section is incomplete

Section 1: Must be completed by all claimants

Section 1: Contact Information
Must be completed by all claimants
First Name*
Last Name*
Phone Number*
Email Address
Address*
Date of Incident*
Time Incident*
Location of Incident*
Detailed Description of Incident*
Police Report Made? If yes, Police Report #
Photo Taken? If yes, please upload...
Witness Name
Telephone Number
Relationship
Address
Witness Name
Telephone Number
Relationship
Address
Continue

Section 2: Claims Concerning Vehicle Damage or Automobile Accident

Vehicle Make
Vehicle Year
Type
License No.
Owner's Name
Owner's Address
Driver's Name
Driver's Address
Was anyone injured? If yes, complete Personal Injury section.
1. Yes
2. No
Number of People in Car:
Name of Injured Person
Address
Name of Injured Person
Address
Name of Other Vehicle Occupant
Address
Name of Other Vehicle Occupant
Address
Auto Insurance Company Name
Medical Insurance Company Name
Estimated Repair Cost
Deductible Amount
Describe Damage
Continue |Go Back

Section 3: For Claims Concerning Personal Injury

Nearest Address of Incident Occurrence
Nature and Extent of Your Injury
Attending Physician Name
Attending Physician Address
Total Type of Medical Expenses To Date
Medical Expenses To Date
Amount Paid by Insurance
Amount Paid By You
Amount of Wages Lost
Health Insurance Company Name
Deductible Amount
Name of Hospital Transported To
List and Explain Any Physical Disability
Provide Date and Nature Of Any Prior Injuries
Continue |Go Back

Section 4: Claims Concerning Property Damage Other Than Automobile

Cause of Damage
Village Employee Contacted
Date
Name of Insurance Company
Deductible Amount
I hereby attest that the above information is true to the best of my knowledge and belief.
1. Yes

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Village of Bensenville
12 S Center Street
Bensenville, IL 60106
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Phone: 630-766-8200
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