Chun-Ha Insurance services, inc.

* indicates mandatory information

Policyholder Identification


First Name*

Last Name*

Street Address*

City*

State*

Zip Code*

Phone Number*

Fax Number*

Best Time to Contact You*

E-mail Address*

Policy Number*

Description of Accident


Type of Claim*

Date and Time of the Incident*

Location of the Incident*

Accident Description*

Police Report Number

Other Vehicle Description (if include year, make, and model)

Other Driver Contact Information (Names, Addresses, Phone, etc)

Other Vehicle Insurance Company Name

Other Vehicle Insurance Policy Number

Witness Contact Information (Names, Addresses, Phone, etc)

Comment

Final Step

Thank you for completing the Chun-Ha Insurance Claim Form. A representative will attempt to contact you within two business hours of assignment of this claim.

For Homeowners & towing claims, please contact (714)537-5000

Please indicate how we can best contact you by selecting an option below*


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