Name *

Today's Date *
Select a date from the calendar.

Mailing Address

City

State

Zip Code

Email

Phone Number *

Date and Time of Loss *
Select a date from the calendar.  

Weather Conditions

Exact Location of Loss *

Injuries as a Result

Property Damage

Transported for Medical Treatment?

Medical Facility/Doctor

Drivers Name and DL#

Tag #

Year/Make/Model

Owner of Vehicle

Insurance Company and Policy Number

Police Report #

Agency (i.e, FHP, Sheriff, CCPD, FMPD, etc.)

Name/Phone # of any Passenger(s)

Were there any witnesses? *

If Yes, please list Name, Address and Telephone Number

In your own words, describe what happened *

In your opinion, how is Lee County responsible for your loss *

* Florida Statute 817.234, requires the following statement on claim forms:
Any person who knowingly and with intent to injure, defraud, or deceive any
insurer, files a statement of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony of the third degree.

Signature *

Date *
Select a date from the calendar.

Attachments