Clear Spring Property & Casualty Company Administered by Jubilee General Agency 888 W Sam Houston Pkwy S, Suite 188 Houston, TX 77042 Office:1-844-949-7788 Fax: 713-490-3214Email: claims@jubileemga.com Spanish ONLY YesNo Accident Not in TX YesNo First Name Last Name Do you have / Please send any photos that you took at the time of the incident If they do ask them to Text the photos to 281-619-8998 YesNo Address Contact Info Best Contact Times / Days Preferred Method Additional Information Name of driver involved in accident Contact number of driver involved in accident: Email address of driver involved in accident: Current Address of driver involved in accident: Do you have insurance with us YesNo (If yes, please complete information below) Policy Number Policy Name (MM/DD/YYYY) Effective Date (MM/DD/YYYY) Expiration Date Coverage (MM/DD/YYYY HH:MM) Date / Time of Incident Location Address Inspection Immediately after the Incident? YesNo Type of Loss CollisionTheftFloodFireVandalismHailOtherBodily Injury Only Description of Loss Cause of Loss Do you Drive for Uber or Lyft? YesNo Were you driving for Uber or Lyft at the time of the incident? YesNo Do you have insurance? YesNo Who is your carrier? What is your Policy Number? Where were you driving to and From? Description of Damage Include Stolen Items if Applicable Estimate of Damages ($) Bodily Injury YesNo Level of Damage LightModerateHeavyTotal Loss Were Authorities Contacted YesNo Which Authority(ies) Police Name / Phone Report / Violation No Citation Issued Ambulance Called Other Name / Phone Report / Violation No Witness Name / Phone Address Was Suspect Apprehended YesNoN/A Is this a Notice Only Claim? YesNo Driver Type InsuredClaimant Vehicle Drivable YesNo Air Bags Deployed YesNo Was Vehicle Towed YesNo Add Towing Vehicle Co Name: Towing Co Telephone Number: Address Vehicle was Towed to: First Name Last Name Date of Birth Company Name Lien Holder Address City State Zip Email Phone DL Number / State Vehicle Type AutoMotorcycleRVTruckBoatTrailer Year Make Model Color Plate No Plate State Make VIN Vehicle Location Now Same as AboveUnknownDifferent Location (Enter Below) Location Name Location Phone Address City State Zip Passenger Information Passenger Information Injuries (If Any) Vehicle at Shop or Storage Lot YesNo Air Bags Deployed YesNo Vehicle Still Drivable YesNo Driver Type InsuredClaimant Vehicle Drivable YesNo Air Bags Deployed YesNo Was Vehicle Towed YesNo Add Towing Vehicle Co Name: Towing Co Telephone Number: Address Vehicle was Towed to: First Name Last Name Date of Birth Company Name Lien Holder Address City State Zip Email Phone DL Number / State Vehicle Type AutoMotorcycleRVTruckBoatTrailer Year Make Model Color Plate No Plate State Make VIN Vehicle Location Now Same as AboveUnknownDifferent Location (Enter Below) Location Name Location Phone Address City State Zip Passenger Information Passenger Information Injuries (If Any) Vehicle at Shop or Storage Lot YesNo Air Bags Deployed YesNo Vehicle Still Drivable YesNo Driver Type InsuredClaimant Vehicle Drivable YesNo Air Bags Deployed YesNo Was Vehicle Towed YesNo Add Towing Vehicle Co Name: Towing Co Telephone Number: Address Vehicle was Towed to: First Name Last Name Date of Birth Company Name Lien Holder Address City State Zip Email Phone DL Number / State Vehicle Info Vehicle Type AutoMotorcycleRVTruckBoatTrailer Year Make Model Color Plate No Plate State Make VIN Vehicle Location Now Same as AboveUnknownDifferent Location (Enter Below) Location Name Location Phone Address City State Zip Passenger Information Passenger Information Injuries (If Any) Vehicle at Shop or Storage Lot YesNo Air Bags Deployed YesNo Vehicle Still Drivable YesNo Driver Type InsuredClaimant Vehicle Drivable YesNo Air Bags Deployed YesNo Was Vehicle Towed YesNo Add Towing Vehicle Co Name: Towing Co Telephone Number: Address Vehicle was Towed to: First Name Last Name Date of Birth Company Name Lien Holder Address City State Zip Email Phone DL Number / State Vehicle Info Vehicle Type AutoMotorcycleRVTruckBoatTrailer Year Make Model Color Plate No Plate State Make VIN Vehicle Location Now Same as AboveUnknownDifferent Location (Enter Below) Location Name Location Phone Address City State Zip Passenger Information Passenger Information Injuries (If Any) Vehicle at Shop or Storage Lot YesNo Air Bags Deployed YesNo Vehicle Still Drivable YesNo Name Business Name Address City State Zip Phone Fax Email