Automobile Loss Notice
Date of Loss and Time:
Contact Information (insured)
First Name:
E-mail:
Last Name:
Home Tel #:
(+ area code)
Address:
Bus Tel #:
(+ area code, ext)
Social Sec #:
Where to contact:
home
work
both
When to contact:
anytime
9am to 12pm
12pm to 5pm
any day
week days
weekends
Loss
Location of Accident:
(include city and state)
Violations/Citations:
Authority Contacted:
Report #:
Description of Accident:
include as much information as possible
Your Vehicle
# of vehicles
1
2
3
4
5
> 5
Year:
Make:
Model:
Plate Number:
State:
select
AL
AZ
AR
CA
CO
CT
DE
FL
GA
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Owner's Name & Address
First Name:
Address:
Last Name
:
Home Tel #:
(+ area code)
Bus Tel #:
(+ area code, ext)
Driver's Name & Address
(check if same as owner)
First Name:
Home Tel #:
Last Name
:
Bus Tel #:
(incl ext)
Relation to insured:
Date of Birth:
Driver's License#:
State:
select
AL
AZ
AR
CA
CO
CT
DE
FL
GA
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Purpose of Use:
Used with permission?
Yes
No
Describe Damage:
Estimate Amount:
Where can vehicle be seen?
Other insurance on vehicle:
When can vehicle be seen?
Property Damage
Describe Property:
(if auto, year, make, model, plate#)
Other vehicle/property insurance?
Yes
No
Company or agency name:
Policy #:
Owner's Name & Address
First Name:
Home Tel #:
Last Name
:
Bus Tel #:
(incl ext)
Other Driver's Name & Address
(check if same as owner)
First Name:
Home Tel #:
Last Name
:
Bus Tel #:
(incl ext)
Describe Damage:
Estimate Amount:
Where can damage be seen?
Who is Injured?
Were you (the insured) injured?
Yes
Describe your injuries
No
Others Injured?
Name & Address
Phone (area+num)
Pedestrian
Other Driver?
Extent of Injury
Witnesses or Passengers
Name & Address
Phone (area+num)
Your Vehicle?
Other Vehicle?
Other (Specify)
Statement that the claimant agrees that all the information submited in this form is truthful, and that they understand fraudulent claims are illegal and can be prosecuted by law etc etc etc...
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