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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#:


Company:


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 :


Your Claim Number from Another Insurer (e.g. State Farm 123456E) and Additional Details :


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.