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Agency

Policy

Insured

Contact

Location of Loss

Loss

Insured Vehicle

1. WAS A STANDARD CHILD PASSENGER RESTRAINT SYSTEM (CHILD SEAT) INSTALLED IN THE VEHICLE AT THE TIME OF THE ACCIDENT?

2. WAS THE CHILD PASSENGER RESTRAINT SYSTEM (CHILD SEAT) IN USE BY A CHILD DURING THE TIME OF THE ACCIDENT?

3. DID THE CHILD PASSENGER RESTRAINT SYSTEM (CHILD SEAT) SUSTAIN A LOSS AT THE TIME OF THE ACCIDENT?

Other Vehicle / Property Damaged

Injured

INJURED 1

INJURED 2

Witnesses or Passengers

WITNESS / PASSENGER 1

WITNESS / PASSENGER 2

Remarks

For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

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