Claimant’s report of automobile damage
Your vehicle
Owner ____________________________ Address ___________________________ Phone __________________
___________________________
Driver _____________________________ Address ___________________________ Phone __________________
___________________________
Insurance company _________________________________________ Car parked and
unoccupied occupied
Make of car _________________ Type __________________ Model ___________________ Year _______________
License plate # _____________________ Damage _____________________________________________________
Estimated repairs $ __________________ Where car may be seen ________________________________________
Peoples Gas vehicle
Driver __________________________________________________________________________________________
License plate/vehicle # ___________________________ Type of car ______________________________________
Occupants of car
Name _____________________________ Address _____________________________________________________
Name _____________________________ Address _____________________________________________________
Injuries
Name _____________________________ Age _______ Address _________________________________________
Describe injury ________________________________________________ Taken to _________________________
Name _____________________________ Age _______ Address _________________________________________
Describe injury ________________________________________________ Taken to _________________________
Witnesses
Name _____________________________ Address _____________________________________________________
Name _____________________________ Address _____________________________________________________
Accident information
Date of accident ____________________ Time _______
a.m. p.m. Weather _________________________
Location of accident ______________________________________________________________________________
Police notified?
Yes No Ticket issued? Yes No To whom? ______________________________
Violation __________________________ Court date ____________________ Time _____________
a.m. p.m.
Police report # ______________________
Description of accident ____________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Date of report _____________ Time of report ________
a.m. p.m. Reported by _______________________
Return to: Peoples Gas Company – Attention: Claim Services
• Mail: 200 East Randolph Street, Chicago, Illinois 60601
• Fax: 312-240-4370
• Email: Claims@peoplesgasdelivery.com
Questions: Call 866-227-2941
