Third Party Claim Reporting Form

Incident/Claim Information

Incident Type

Incident Date

Incident Time

Format Example 06:45am or 12:06pm

Incident Address

Incident City

Incident State/Province

Incident Country

Incident Description

Be detailed as possible. Direction of travel, weather conditions, etc. Was Law enforcement called? Please list case/incident number and officer information if available.

Vehicle / Equipment / Trailer Involved?

Property Damage?

Estimated Damages/Losses ($)

Please insert dollar amount only.

Claimant Details

First Name

Last Name

Please enter email address to receive an email receipt of your submission.

Birthdate

Phone

Mobile Phone

Mailing Street

Mailing City

Mailing State/Province

Mailing Country

Mailing Zip/Postal Code

Description of Personal Injuries

Please be as detailed as possible and note if you are a medicaid/medicare recipient.

Care from Emergency Medical Services?

Seek Medical Attention?

Health care provider's name

Provider name and facility

Claimant Medical Insurance Company

Claimant Medical Policy Number

Claimant Medical Claim Number

If known.

Do you wish to add Involved Persons?

"Involved Person" is an individual who is/may be involved with the claim/incident (directly or indirectly) being reported. (Examples include the claimant, witness to the Incident, lawyer, property manager, employees, etc.)

Involved Person Details

Involvement Type

First Name

Last Name

Phone

Mobile Phone

Mailing Street

Mailing City

Mailing State/Province

Mailing Country

Mailing Zip/Postal Code

Description of Personal Injuries / Description of Involvement

Sustained Injury?

Seek Medical Attention?

Care from Emergency Medical Services?

Health care provider's name

Call Phone Number from Ambulance Call Report

Have you received any other medical aid?

Part of Body

Select multiple by holding "ctrl".

Nature of Injury

Select multiple by holding "ctrl".

To add another involved person, please select "Add another response" on the bottom-right portion of this section. This will open another section where information can inserted. If not required, please ignore.

Involved Vehicle / Equipment / Trailer

Matanuska-Susitna Vehicle or 3rd Party Vehicle

Vehicle Unit #

Vehicle Make

If make not known, please insert "N/A"

Vehicle Model

Vehicle License Plate Number

Vehicle Year

Vehicle Type

Description of Damages

Please be as detailed as possible and submit any photos available.

To add another vehicle, please select "Add another response" on the bottom-right portion of this section.

Involved Property (Non-Auto)

Type of Property

Property Address

Description of Damages

Please be as detailed as possible and submit any photos available.

To add another vehicle, please select "Add another response" on the bottom-right portion of this section.

Attachments

Do you wish to add Files/Attachments?

Note: There is a 25 MB per file size limit, a 35 MB total file size limit, and a 10 file limit per submission.

Please upload any supporting documents, images, invoices, or estimate of damages.

File Upload

To add more than one attachment, select "Add Another Response". To remove the additional file upload option, select "Remove".

A person who knowingly and with intent to injure, defraud, or deceive an insurance company, files a claim containing false, incomplete, or misleading information may be prosecuted under state law. By submitting this form you acknowledge that the information provided is true and correct to the best of your knowledge. You also acknowledge that submitting this form is not a guarantee of settlement or an admission of liability by the Matanuska-Susitna-Borough, any of it's elected and appointment officials, administrators, officers, agents, employees or volunteers. Failure to complete all sections of this form will delay the processing of your claim and may result in the return or denial of your claim.