Third Party Claim Reporting Form

Third Party Incident Notice

* - Denotes mandatory field

Your Name*:

Your Relation to the Loss*:

Who do you Represent (e.g. Self or Attorney for ________ )?*:

Your Email Address*:

Your Phone#*:


Partner Driver Name*:

Partner Driver Phone# :

Vehicle Year / Make / Model :

License Plate :

Incident Date*:

Time of Incident*:

Country* :

State* :

City* :

Intersection/Location of Incident* :

Description of Incident :

Additional Details :

Note: Please note that the limit for all attachments is 25 MB.

File Attachments:

Our receipt of this information does not constitute and should not be construed as an admission of liability or a commitment to coverage or payment under an insurance policy. The information transmitted to James River Insurance Company may be shared with a third party for driver validation. Please allow for 36 hours to process your claims notice before resubmitting.