Chicago Area Claim Form

730 Birginal Drive
Bensenville, Illinois 60106
Toll Free 888.345.2700
Fax 630.616.1705

> Chicago Area Claim Form

Please take a moment to fill out this form, a representative from C.I.S. will contact the insured. Fill out as much information as possible to help expedite the claim. Depending on the claim, some information may not be necessary. If you have any questions, please include them in the bottom section of this form.

Wheel Claim Form

Insurance Company Information:

Insurance Company:
Claim Number:
Adjusters Name/Team Number:
Phone Number: Ext. Number:
Deductible:
Additional Electronics Coverage: If Yes, How Much:
Betterment: If Yes, what %:

Insured's Information:

*Name:
Address:
City: State: Zip Code:
*Home Phone:
Work Phone:
Cell Phone / Pager Number:
*E-Mail Address:

Vehicle Information:

Make: Model:
Year:
V.I.N. Number:
Exterior Color:
Vehicle Location:
Location's Number:
Stock Number:

Theft or Damage Information

Electronics: Dash Damage (In if the Chicago Area):

Restoration Information:
Odor: Burn/Smoke: Spills: Wheel/Tire:

Flood: Rodents/Bugs: Blood: Convertible Top:

Equipment to be replaced:

Services & Documentation

Questions or Comments:

Thank you for using C.I.S.'s Internet Claim Service!