AUTO CLAIM FORM 123456

PLEASE FAX ALL CLAIMS TO:

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Date of Accident:07/13/2023 Time:15:38 PM

Police Dept Notified: Woonsucket Case #:

VEHICLE #1: (Insured’s Vehicle)

Type of vehicle: Ford Focus Year: 2011 Make: Red Model: Focus

VIN #: 1FAHP3FN2BW131889 License Plate # 3TAC35

DRIVER/NAME/ADDRESS/#: Santiago Paulino Ramirez/ 34 norton street Ma Hyde park 02136

Email Address:

Description of Damages: Fron left corner,

Body Shop Information (if taken): Roys Towing

Address:
Phone:

VEHICLE # 2: (other Vehicle)

Insurance Info: Company:Philadelfia Indeminity Policy #

Type of Vehicle: FordYear 2021Make WhiteModel Transist

VIN # 1FDAX2C89MKB01511 License Plate # 97496

Driver Info: Name: Mina Roufaeil D/License # 40109120

Address: 1077 park av 2 City woonsucket State: Rhode Island Zip 22815

Description of Damage to Vehicle: Right front corner

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Description of Accident: Mina was driving his vehicle when he got rearended by Santiago at the
intersection of Social st And Charles St.

Person (s) Injured:

Name: Mina Roufaeil Address: 1077 park av 2 City woonsucket State: Rhode Island Zip 22815

Phone# (401) 696-0895 Vehicle # 1 or 2

Nature of Injuries: Head trauma, neck pain, taken to Landmark Medical Center

Person (s) Injured:

Name:Santiago Paulino Ramirez Address: 34 norton street Ma Hyde park 02136

Phone # Vehicle # 1 or 2

Nature of Injuries: Unknown, Taken to Landmark medical center