Untitled Document

Automobile Loss Notice

Please use the form below to notify us of any loss or damage to your automobile(s) insured through this company/agency. Please not that this form is for notification purposes only and does not constitute making an actual claim. One of our representatives will contact you shortly after receiving this notification.

Disclaimer:

By clicking on the sumbit button below you are agreeing to the following:

I understand that this does not constitute an actual claim, but is rather a notification to my agent of an existing loss or claim, and may help expedite the claim process once I have filed.

Page 1 - Policy Holder Information
Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.
Choose your Office:
Name Insured:
Address:
City:
State:
Zip Code:
Work Phone:
Home Phone:
Email:

<< Previous ][ 1 2 3 4 5 6 7 ][ Next >>

Please click on the "Submit" button to send your Loss Notice. One of our representatives will respond to your submission as soon as possible.

Page 2 - Time and Location of Accident
Time:
		A.M. P.M.
Date:
Location of Accident: (Number, Street, Intersection, etc.)
Description of Accident:

Page 3 - Police Notification
Were the Police Called?		Yes No
What Authority?
Were you Ticketed?		Yes No
If Yes, what for?

Page 4 - Vehicle Information
Damage to Your Vehicle?		Yes No
If Yes, describe:
Where Can Vehicle Be Seen?
Vehicle Year:
Make:
Model:
License Plate Number:
State:
Is This Your Car?		Yes No
If No, were you using it with permission?		Yes No
Please Explain:

Page 5 - Other Driver Information
Name:
Address:
Work Phone:
Home Phone:
Vehicle Year:
Make:
Model:
Driver's License Number:
Driver's License State:
License Plate Number:
Licens Plate State:
Insurance Company:
Describe Damage to Other Vehicle:
Where Can Vehicle Be Seen?
If There Were Any Injuries, Please Describe:
Please List Any Witnesses and/or Passengers: (Please include name, address, and phone)

Page 6 - Report Information
Reported By:
Title (if any):
Date:

Page 7 - Additional Comments
Please give any additional comments you feel appropriate for this Loss Notice.