Name *
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Today's Date *
You must specify a value for this required field.
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Mailing Address *
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City *
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State *
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Zip Code *
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Email
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Phone Number *
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Date and Time of Loss *
You must specify a value for this required field.
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Weather Conditions
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Exact Location of Loss *
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Injuries as a Result
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Property Damage
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Transported for Medical
Treatment?
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Medical Facility/Doctor
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Drivers Name and DL#
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Tag #
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Year/Make/Model
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Owner of Vehicle
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Insurance Company and Policy
Number
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Police Report #
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Agency (i.e, FHP, Sheriff, CCPD,
FMPD, etc.)
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Name/Phone # of any Passenger(s)
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Were there any witnesses? *
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If Yes, please list Name, Address
and Telephone Number
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In your own words, describe what
happened *
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In your opinion, how is Lee
County responsible for
your loss *
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*Florida Statute 817.234, requires the following
statement on claim forms:
Any person who knowingly and with
intent to
injure, defraud, or deceive any insurer, files a
statement of claim or an application containing
any false, incomplete, or misleading information
is guilty of a felony of the third degree.
Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a
statement of claim or an application containing any false,
incomplete, or misleading information is
guilty of a felony of the third degree.
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Signature *
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Date *
You must specify a value for this required field.
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Attachments
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