(Form Below) - GEICO
Instructions
The Vehicle Fire Questionnaire is a written statement you provide to document the details of the fire. To complete this form properly, include your claim number, policy number, date of loss, and fill out all sections.
(Form Below)
GOVERNMENT EMPLOYEES INSURANCE COMPANIES Vehicle Fire Questionnaire
Claim Number Policy Number Date of Loss
Name of Insured/Owner: ______________________________________________ Date of Birth: ___________
Residence Address: ___________________________________________________________________________
P
Street
O Telephone Number: Home: _____________________
City
State
Business: ________________________
Zip Code
L How long have you been at the above residence? ________________________________________________years
I Previous Residence Address: ____________________________________________________________________
C
Street
City
State
Zip Code
Y Employer Name: _________________________________________________________________________________________
H Address: _______________________________________________________________________________________________________________________
O
Street
City
State
Zip Code
L Occupation/Position: _______________________________________________ Length of Service: ___________
D Social Security Number: __________________________________
E Insured's Driver's License Number: _____________________________________ Registered State: ____________
R /
Marital Status:
Single
Married
Divorced
Separated
Widow
O Spouse's Name: ____________________________________________ Date of Birth: __________________
W
Address: (If different from residence address) ________________________________________________________
N
Street
City
State
Zip Code
E
Telephone Number: Home: ______________________
Business: ____________________
R
Employer: ______________________________________________________________________________
Address: _______________________________________________________________________________
I N
Street
City
State
Zip Code
Occupation: _____________________________________________________________________________
F
Spouse's Social Security Number: ___________________________
O
Spouse's Driver's License Number: ________________________________ Registered State: ___________
R
M
Drivers Residing
NAME/RELATION
SEX
DATE OF BIRTH DRIVER'S LICENSE NUMBER
A
In Household
Male
Female
T
Male
Female
I
Male
Female
O
N
Other Vehicles Located
At Residence Address
YEAR
MAKE
MODEL
PLATE NO.
INSURANCE COMPANY
V VEHICLE IDENTIFICATION NUMBER (VIN): ______________________________________________
E
H I C
State: ______________ License Plate Number: ______________________________ Mileage _______________ Year: _____ Make: ______________ Model: ___________________ Color: __________ Special Packages: ___________
L CHECK SPECIFICATIONS AND EQUIPMENT THAT APPLY BELOW:
E Body Style: 2dr
4dr Lift/Hatchback Convertible Wagon Van Pickup Other: _______________
Engine Detail: Size: ________ Cylinders: 3
4
5
6
8
12
Turbo
Diesel
D Transmission: Automatic 6 Speed 5 Speed 4 Speed 3 Speed Optional: Override Overdrive 4 Wheel Drive
E
S C R I P
POWER OPTIONS Pwr Steering Pwr Brakes Pwr Windows
D?COR/CONVENIENCE Air Conditioning Rear Defogger Tilt Wheel
RADIO AM FM Stereo
T
Pwr Locks
Cruise Control
Cassette
I
Pwr Drive Seat
Leather Seats
Seek/Scan
ROOF OPTIONS Vinyl Roof Electric Steel Electric Glass Manual Steel Manual Glass
MOTORCYCLES Headers Full Fairing Plexi-Faring Custom Seat Saddle Bags
O
Pwr Pass Seat
4 Whl Disk Brakes
CB Radio
Flip Roof
Travel Trunk
N
Air Bag
Telescopic Wheel
Telephone
T-Tops
Engine Guard
Anti-Lock Brakes
Auto Load Level
Anti-Theft Device Roof Rack
Case Guard
3rd Seat (wagons only)
CD Player
Soft Top
Back Rest
Wire Wheels
Hard Top
Wire Wheel Cover
- 1 C-221 (03-14) NS
(Continued)
OTHER OPTIONS
V
Step Bumper
E
Sliding Rear Window
H.
Auxiliary Fuel Tank
D
Sport Wheels
E
2-Tone Paint
S
Deluxe 2-Tone Paint
C.
Customizing (Interior/Exterior)
Any Additional Options
Deep Tinted Glass Dual Air Conditioning Running Boards Fog Lights Bedliners Chrome Bed Rails
Trailering Package Eight Passenger Roll Bar Tool Box (Permanent) Grill Guards Positraction
Purchase/Lease Date: _______________
NEW
USED
Purchase Price: $____________
Paid By:
CASH
CHECK
Financed By: _______________________________________
Seller's Name: __________________________________ Telephone Number: ______________________
S
Address: ________________________________________________________________________________
A Tax Paid: $_________________________ Trade In?
NO
YES $_________________________
L Lienholder/Leasing Co. Name: ___________________________________________________________________
E
Address: ________________________________________________________________________________
S
Street
City
State
Zip Code
Telephone Number: ___________________________
D
Account Number: _______________________________ Down Payment: $__________________________
A T
Last Payment: $_________________________________ Date: ___________________________________
A
Has vehicle been repossessed?
NO
YES
Are payments up to date?
YES
NO Lienholder notified of FIRE?
YES
NO
Other outstanding loans?
NO
YES With Whom? _________________________________
Amount? $___________________________________
Owner(s) as shown on title: __________________________________________________________________
S Name of Service Station: ____________________________ Telephone Number: ________________________
E Address of Service Station: ______________________________________________________________________
R
Street
City
State
Zip Code
V Date of Last Service: _____________________ Work Performed: ___________________________________
I List any work performed since purchase other than tune-up, oil, grease: ___________________________________
C ____________________________________________________________________________________________ E When & Where Repaired: _______________________________________________________________________
P Has vehicle been involved in any losses since its purchase?
NO
YES
R Date of Loss: _____________________ Location: _________________________________________________
I Type of Loss: _________________________________________________________________________________
O Damages/Area: _______________________________________________________________________________
R Amount: $____________________________________ Repairs Completed?
NO
YES
D Insurance Company: ___________________________________________________________________________ A Repair Shop Name: _______________________________ Telephone Number: ________________________
M
Address: ________________________________________________________________________________
A
Street
City
State
Zip Code
G Was there any unrepaired body or mechanical damage on the vehicle prior to the fire? NO YES
E If "YES" list damages: ____________________________________________________________________________
F Who had custody of vehicle at the time of the fire? (If other than insured, complete part 1) _____________________ I Exact location of fire: (If subro, complete part 2 ) _____________________________________________________
R Reason car at location: _________________________________________________________________________
E Date and time vehicle last seen before fire: _____________________
____________ A.M.
P.M.
I N
Date and time fire was discovered: _____________________
____________ A.M.
P.M.
F How many set of keys? ______________ Who has extra keys? ________________________________________
O. Are there any keys missing?
NO
YES
Were there any keys in or upon the vehicle?
NO
YES Where? __________________________
Was the vehicle locked?
NO
YES Alarm in use?
NO
YES?
N/A
(Continued)
C-221 (03-14) NS
- 2 -
Briefly describe activity 24 hours prior to fire:
F Briefly describe activity 24 hours after fire: I R E
Have you or any member of your family ever had a vehicle fire?
NO
YES
I If yes, Date: ____________________ Location: _________________ Insurance Company: ________________________
N Do you have any other Insurance on the vehicle?
F
O Do you have a Homeowners
or Tenants
NO Policy?
YES _____________________________________
R Is the vehicle that is reported legally registered and titled at the Department of Motor Vehicles that issued the title and plates?
M
YES
NO
A T
If the identity of the person or persons responsible for the fire of this vehicle is established, are you willing to prosecute that
I person or persons?
YES
NO
O When was your last insurance claim: _____________________
N Name of Company: _______________________________________________________________________________________
P
O Who notified the Fire Dept.?
L __________________________________________________________________________________
I
C Fire Dept.: _________________________ Address: ___________________________________________________________
E
Street
City
State
Zip Code
/ F
Case Number: ___________________ Officer: ____________________________ Badge Number: ___________________
I R
Date and time fire reported: _____________________ Time: _________
A.M.
P.M.
E Fire loss reported to: _____________________________________________ Insurance Company D
E Date _____________________ Time: _______ A.M. P.M.
P T. To Whom ______________________________________________________________________________________________
I
N
F
O.
IF VEHICLE WAS LOANED OR BORROWED:
P Name: __________________________________________________ Telephone Number: _________________________
A Address: _______________________________________________________________________________________________
R
Street
City
State
Zip Code
T Relationship: ___________________ Purpose: ______________________ Does borrower own a vehicle? YES NO
1 If yes: Vehicle Year: ________ Make: ___________ Model: _______________ License Plate Number: _____________
Insurance Company: ________________________________________________________________________________
SUBROGATION:
If the vehicle was parked in a garage or parking lot, identification of place of fire:
P _________________________________________________ A Address: ____________________________________________________________________________________________________ R T Insurance Company: __________________________________________________________________________________________
2 Ticket Number: ______________________________ Lease: _____________________________________
Stub Number: _______________________________ Who parked the car? _____________________________________________
Who was given possession of keys ? Attendant: _____________________________________________________________________
(Continued)
3
C-221 (03-14) NS
IF THERE WERE ANY PERSONAL ITEMS IN YOUR VEHICLE THAT WERE DAMAGED OR DESTROYED
P AND IF YOUR POLICY PROVIDES COVERAGE FOR PERSONAL EFFECTS, PLEASE COMPLETE THIS E SECTION:
R
(LIMIT $200.00)
S
O
LIST ITEMS
N
VALUE OF EACH ITEM
A
L
E
F
F
E
C
T
NOTE: LOSS TO ANY TAPE, WIRE, RECORD DISC OR OTHER MEDIUM FOR USE WITH A DEVICE
S
DESIGNED FOR THE RECORDING AND/OR REPRODUCTION OF SOUND IS NOT COVERED.
(OTHER EXCLUSIONS MAY APPLY)
I swear that the above four (4) pages are true and correct to the best of my knowledge. Name: _______________________________________ Address: _____________________________________ Signature: ____________________________________ Date: ________________________________________
C-221 (03-14) NS
4
................
................
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