Dealer Open Lot Claims

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Loss Detail Information

Date of Loss

Time Of Loss

Loss Type

Location of Loss

Street Address Address Line 2 City State ZIP Code

Description of Loss

Insured Detail Information

Policy Number

Insured Name

Address

Street Address Address Line 2 City State ZIP Code

Contact Phone(Required)

Contact Email(Required)

Contact Name(Required)

Agent Detail Information

Agency Name

Contact Name

Agent Email

Agency Phone Number

Agency Contact Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Drivers

Insured Driver

Insured Driver Address

Street Address Address Line 2 City State ZIP Code

Insured Vehicle VIN

Insured Vehicle Description

Claimant Driver

First Last

Claimant Driver Address

Street Address Address Line 2 City State ZIP Code

Claimant Vehicle

Claimant Vehicle VIN

Claimant Vehicle Description

Address

15301 Dallas Parkway, Ste 500
Addison, TX 75001

Phone

Toll Free: (844) 410-9201
Fax: (469) 209-1595

Email

info@mobilityclaims.com
claimreporting@mobilityclaims.com

Fraud Reporting

Fraud Hotline: 800-342-3504
fraudreporting@mobilityclaims.com

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Loss Detail Information

Insured Detail Information

Agent Detail Information

Drivers

Address

Phone

Email

Fraud Reporting