Cafarelli Insurance Agency Ltd
Tel: 631.543.6363 Fax:631.543.4891
1030 Jericho Tpke. Smithtown, NY 11787
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Description of Loss and/or Injury
If Auto Claim (Personal or Business)
Year of your Vehicle
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V.I.N. of your Vehicle
Driver of your Vehicle
Driver's Date of Birth
Driver's License Number
Driver's Address and Phone Number
Info on Other Vehicles Involved
Injuries to Vehicles - Your Vehicle or other Vehicles
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If Yes, Describe Injuries
If Workers Compensation Claim
Name of Injured Employee
Address of Injured Employee
Phone Number of Injured Employee
SS Number of Injured Employee (claims are tracked by employees' SS #)
Your Contact Info
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