Markel Corporation (7535)

NetClaim Auto Liability

The Network Inc. Report# MKL121503356 / TNW# 121503356 Page 1 of 2

Client Information Report Information

Name: REYMOND SANTANA Report Number: MKL121503356
UNK_FL Report Created: 5/27/2015 8:14:00 AM Eastern
Address: 1317 GOLFSTREAM CIRCLE Escalated:
APT 204
BRANDON, FL 33511
Business Phone: (813) 785-1551
Insurance Information
Caller Information
Policy Number: MMT00000295635
Name: LISA RODGERS
Insurer Name: Markel Corporation
Job Title: THIRD PARTY CALLER
Address: 1317 GOLFSTREAM CIRCLE
Business Phone: (813) 850-8203
APT 204
BRANDON, FL 33511
Insurer Phone:
Home Phone:
Policy Dates:
Address:
FEIN:
Incident Information
Authorities
Occurred: 05/24/2015 6:30 pm
Reference Num: 15322746
Employer Notified:
Title: HILLSBOROUGH COUNTY SHERIFF
Location: INTERSECTION
LUMSDEN AND SOUTH KINGS AVE Phone:
BRANDON, FL 33511

Description: IV was travelling normally when it slid and lost control, hitting pavement. Damage to the IV. Injuries to the IV
driver.
Involved Parties
Involvement: Insured Driver
Name: REYMOND SANTANA
Address: 1317 GOLFSTREAM CIRCLE
APT 204
BRANDON, FL 33511
County: Country: USA
Work Phone: (813) 785-1551 Home Phone: (813) 785-1551
Date of Birth: 11/6/1973 Date of Death:
Social Security Num:
Drivers License Num: S525720734060 State: FL
Citation Received: NONE
Relation to Insured: SELF
Medical Prov Name: UNK Hospital Name: TAMPA GENERAL HOSPITAL
Med Prov Address: UNK Hospital Address: UNK
UNK UNK
Med Prov Phone: Hospital Phone:
Medical Transport: AMBULANCE
Injury Description: MOTOR VEHICLE ~ MOTOR VEHICLE, NOC - MULTIPLE BODY PARTS ~ MULT
Vehicle

Insured Vehicle
Type: OTHER Location: REYMOND SANTANA
Make: HARLEY DAVIDSON Address: 1317 GOLFSTREAM CIRCLE - APT 204 -
BRANDON - FL 33511
Manufacture Date: 1/1/2002 Owner Same As Driver: Yes
Model: XL 1200C Owner's Name: REYMOND SANTANA
Body Type: MOTORCYCLE Address: 1317 GOLFSTREAM CIRCLE - APT 204 -
BRANDON - FL 33511
 Markel Corporation (7535)
NetClaim Auto Liability

The Network Inc. Report# MKL121503356 / TNW# 121503356 Page 2 of 2

Color: BLUE Business Phone:

Tag: 0489NE Residence Phone: (813) 785-1551
State: FL Part: 9999 - Not Provided/NOC/Insufficient Data
VIN: 1HD1CGP102K159190 Cause: 1061 - Lost Control
VEH/Asset/Fleet #: UNK Result: 0021 - Towing
Estimated Damage: $0.00 Insurance Carrier: MARKELL AMERICAN INS
Towed: Yes Policy ID: MMT00000295635
Damage Description: damage unk

Client Instructions
Your report number is MKL121503356. Your loss will be set up and a claims specialist will be assigned on the next business day.
If you do not hear from a claims specialist by the second business day, you should call 800-362-7535 and provide your reference
number. Thank you for calling Markel.

Supplementals

Policy Information
What is the policy number for this incident? MMT00000295635
What is the name of the insured company? REYMOND SANTANA

Additional Dissemination Information

Would you like a fax or email copy of this report? EMAIL
What is the Recipient's Email Address? rsantana4u@yahoo.com

General Inquiry Information

What is your relationship to the insured? Other

Additional Claim Information

Did the claim involve a watercraft? NO
Does this claim fall into any of the following categories? None of the Above
Is this claim related to a recent catastrophic event? NO

Escalation
IS DO NOT ASK: Is the caller requested immediate NO
contact from an adjuster?

Notes
Notes/Additional Comments NONE