Affidavit of Vehicle Fire To complete this form by hand: 1 Print all pages of the form. 2 Complete the form by filling in each space with black or blue ink. Do not use pencil. 3 When finished, have your signature notarized before mailing the form to Plymouth Rock’s Claims Department at the address provided at the end of the form. Or To complete this form electronically: 1 Save this writable PDF to your computer, then open it using Adobe’s Acrobat Reader. 2 Complete the form by typing in each field and/or checking the appropriate buttons. Tip: you can tab from field to field. 3 When finished, save and print the form and have your signature notarized before mailing the form to Plymouth Rock’s Claims Department at the address provided at the end of the form. Complete this form to the best of your knowledge and belief. Do not guess at any answers. If you don’t know the answer to a question, leave that field blank. Please call your Claim Representative if you need help. Claim number (12-digit number) personal information First Name of Insured: Last Name of Insured: Date of Birth: / / Social Security Number: – – Driver’s License Number: Street Address: City: State: Zip Code: Home Phone: ( ) – Work Phone: ( ) – Cell Phone: ( ) – Employer: Occupation: Details about the fire Date of Fire: / / Time of Fire: : ◦ am ◦ pm Was the vehicle locked ◦ Yes ◦ No Were keys left in the vehicle ◦ Yes ◦ No Specific Location of Fire: Information about the Person Who Left the Vehicle at this Location First Name: Last Name: Driver’s License Number: Street Address: City: State: Zip Code: Home Phone: ( ) – Work Phone: ( ) – Cell Phone: ( ) – Information about Other People Present at the Fire 1 2 First Name: Last Name: Street Address: City: State: Zip Code: First Name: Last Name: Street Address: City: State: Zip Code: Information about Discovery of the Fire Date of Discovery: / / Time of Discovery: : ◦ am ◦ pm Discovered by Whom: (First & Last Name) Information about Reporting the Fire to the Police and Fire Departments Date Report Filed: / / Time Report Filed: : ◦ am ◦ pm Form continues
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