AUTOMOBILE LOSS NOTICE
* Indicates a required field

DATE OF ACCIDENT AND TIME*

TODAY’S DATE*

Entered By*

INSURED

COMPANY NAME AND ADDRESS*

CONTACT NAME:

CONTACT PHONE:

LOSS

LOCATION OF ACCIDENT (Include City and State)*

AUTHORITY CONTACTED:

VIOLATIONS/CITATIONS

REPORT NUMBER:

DESCRIPTION OF ACCIDENT*

WEATHER:

INSURED VEHICLE

VEH #:

YEAR:  

PLATE NO.:

STATE:

MAKE:

MODEL:

BODY TYPE:

V.I.N.:

OWNER’S NAME AND ADDRESS

RESIDENCE PHONE (A/C, NO.)

BUSINESS PHONE (A/C, NO., EXT):

DRIVER’S NAME & ADDRESS      (Check if same as owner)
FIRST:        
LAST:         
ADDRESS:

RESIDENCE PHONE (A/C, NO.)

BUSINESS PHONE (A/C, NO., EXT):
RELATION TO INSURED (Employee, Family, etc.)
 		DATE OF BIRTH

 		DRIVER’S LICENSE NO.

 		STATE
PURPOSE OF USE

USED W/ PERMISSION?
HOURS OF SERVICE AT TIME OF ACCIDENT:

YEARS WITH INSD:

YEARS AS OTR DRIVER:
NUMBER OF MOVING VIOLATIONS: NUMBER OF ACCIDENTS:
DESCRIBE DAMAGE

 ESTIMATE AMOUNT WHERE CAN VEH. BE SEEN?
WHEN CAN VEH. BE SEEN? OTHER INSURANCE ON VEH.

PROPERTY DAMAGE/CLAIMANT INFORMATION
DESCRIBE PROPERTY (If Auto, Year, Make, Model, Plate #) OTHER VEH/PROP INS?

COMPANY OR AGENCY NAME:
POLICY #:
OWNER’S NAME AND ADDRESS RESIDENCE PHONE (A/C, NO.)
BUSINESS PHONE (A/C, NO., EXT):

DRIVER’S NAME AND ADDRESS     (Check if same as owner)

RESIDENCE PHONE (A/C, NO.)

BUSINESS PHONE (A/C, NO., EXT):

DESCRIBE DAMAGE ESTIMATE AMOUNT WHERE CAN VEHICLE BE SEEN?
WHEN CAN VEHCILE BE SEEN? OTHER INSURANCE ON VEHICLE

INJURED

NAME AND ADDRESS

PHONE (A/C, NO.)

WIT.

INS VEH

OTH VEH

AGE

EXTENT OF INJURY

WITNESSES OR PASSENGERS

NAME AND ADDRESS

PHONE (A/C, NO.)

WIT.

INS VEH

OTH VEH

AGE

EXTENT OF INJURY