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: 713-490-3214
Email: claims@jubileemga.com

Spanish ONLY

Accident Not in TX

Claim Reported By

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

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

Policy Information

Policy Number

Policy Name

(MM/DD/YYYY) Effective Date

(MM/DD/YYYY) Expiration Date

Coverage

Incident Information

(MM/DD/YYYY HH:MM) Date / Time of Incident

Location Address

Inspection Immediately after the Incident?

Type of Loss

Description of Loss

Cause of Loss

Do you Drive for Uber or Lyft?

Were you driving for Uber or Lyft at the time of the incident?

Do you have insurance?

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

Level of Damage

Were Authorities Contacted

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

Is this a Notice Only Claim?

Driver / Vehicle Information 1

Driver Type

Vehicle Drivable

Air Bags Deployed

Was Vehicle Towed

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

Contact Info

Email

Phone

DL Number / State

Vehicle Info

Vehicle Type

Year

Make

Model

Color

Plate No

Plate State

Make

VIN

Vehicle Location Now

Location Name

Location Phone

Address

City

State

Zip

Passenger Information

Passenger Information

Injuries (If Any)

Vehicle at Shop or Storage Lot

Air Bags Deployed

Vehicle Still Drivable

Driver / Vehicle Information 2

Driver Type

Vehicle Drivable

Air Bags Deployed

Was Vehicle Towed

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

Contact Info

Email

Phone

DL Number / State

Vehicle Info

Vehicle Type

Year

Make

Model

Color

Plate No

Plate State

Make

VIN

Vehicle Location Now

Location Name

Location Phone

Address

City

State

Zip

Passenger Information

Passenger Information

Injuries (If Any)

Vehicle at Shop or Storage Lot

Air Bags Deployed

Vehicle Still Drivable

Driver / Vehicle Information 3

Driver Type

Vehicle Drivable

Air Bags Deployed

Was Vehicle Towed

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

Contact Info

Email

Phone

DL Number / State

Vehicle Info

Vehicle Type

Year

Make

Model

Color

Plate No

Plate State

Make

VIN

Vehicle Location Now

Location Name

Location Phone

Address

City

State

Zip

Passenger Information

Passenger Information

Injuries (If Any)

Vehicle at Shop or Storage Lot

Air Bags Deployed

Vehicle Still Drivable

Driver / Vehicle Information 4

Driver Type

Vehicle Drivable

Air Bags Deployed

Was Vehicle Towed

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

Contact Info

Email

Phone

DL Number / State

Vehicle Info

Vehicle Type

Year

Make

Model

Color

Plate No

Plate State

Make

VIN

Vehicle Location Now

Location Name

Location Phone

Address

City

State

Zip

Passenger Information

Passenger Information

Injuries (If Any)

Vehicle at Shop or Storage Lot

Air Bags Deployed

Vehicle Still Drivable

Attorney Information

Name

Business Name

Address

City

State

Zip

Phone

Fax

Email