Auto Loss Notice

Please use the form below to notify our agency about a claim towards your automobile policy. You will contacted shortly by one of our qualified representatives. This does not constitute a cliam until confirmed by one of our agents.

All fields with an (*) are required

Policy Holder Information

Name of Insured

Address

Home Phone

WorkPhone

Insurance Policy #

Time and Location of Accident

Time and Date of Accident
(7:42 pm, December 5, 2007)

Location of Accident
(Number, Street, Intersection, City, etc.)

Description of Accident

Your Vehicle Information

Year of the car you were driving

Make of the car you were driving

Model of the car you were driving

License Plate #

State

Is this your car?
Yes
No

If no, were you using it with permission?
Yes
No

Please explain

Was there damage done to the vehicle?
Yes
No

If yes, please describe

Where can the vehicle be seen?

OTHER Driver Information

Name

Address

Home Phone

WorkPhone

Auto Make

Auto Model

Auto Year

Driver's License #

State

License Plate

State

Insurance Company

Describe damage to other vehicle

Where can it be seen?

Injuries, Witnesses, Etc.

If there were any injuries, please describe

Please list any witnesses and/or passengers
(Please include Name, Address, and Phone)

Police Notification

Were the Police called?
Yes
No

What authority?

Were you ticketed?
Yes
No

If yes, what for?

Report Information

Reported by

Title (if any)

Date

Additional Comments

Please give any additional comments you feel appropriate for this Loss Notice.

Are you human?