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First Claim Report

If you have an accident use this form to record the facts.


1
Contact Information
2
Insured's Information
3
Loss Information
4
Insured Vehicle Information
5
Driver's Information

1. Contact Information

Fields marked with an asterisk (*) are mandatory.
Full Name *
Phone *
Email *

2. Insured's Information

Fields marked with an asterisk (*) are mandatory.
Policy Number *
Full Name *
Address *
City *
State *
Zip Code *
Primary Phone *
Secondary Phone

3. Loss Information

Fields marked with an asterisk (*) are mandatory.
Loss Date *
Loss Time *
Case Number *
Authority Contacted *
Violations / Citations *
Accident Location *
Accident Description *

4. Insured Vehicle Information

Fields marked with an asterisk (*) are mandatory.
VIN Number *
Tag *
Make *
Model *
Year *
Vehicle Location *
State *
Is vehicle Drivable? *
Describe Damage *
Was Vehicle Towed?
Tow Company *
Tow Company Number

5. Driver's Information

Fields marked with an asterisk (*) are mandatory.
License Number *
Full Name *
Address *
City *
State *
Zip Code *
Primary Phone *
Secondary Phone
Email *
Was Anyone Injured? *
Witness *

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If you have an accident use this form to record the facts

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Kingsway AMIGO
Insurance Company

3155 N.W. 77th Avenue
Miami, Florida 33122-3700
Phone: (305)716-6000
Fax: (305)716-6404

Marketing Department

(305)716-6020

For your convenience, our Customer Service Center is available 24 hours a day,7 days a week.