FOR HEALTH INSURANCE FIRST & LAST NAME: INSURANCE ID# INSURANCE NAME DATE OF BIRTH CAR ACCIDENT INSURANCE FIRST & LAST NAME: CLAIM# CLAIM MANAGER'S NAME & NUMBER DATE OF ACCIDENT: CAR INSURANCE NAME: L&I CLAIM FIRST & LAST NAME: CLAIM# CLAIM MANAGER'S NAME & NUMBER DATE OF ACCIDENT: CAR INSURANCE NAME: Note: After you fill out your information, please snap a picture and text it to 253-630-6614 or fax it to 253-630-6624. Should you have questions, please text directly to 253-6
