AUTOMOBILE LOSS NOTICE

Date

Date of Accident and Time

Insured Name

Address

City

State

Zip

Contact Name

Contact Phone

Loss:

Location of Accident: (include city & state)

Authority Contacted

Report #

Violations/Citations

Description of Accident:

Insured Vehicle:

Veh #  Year Make

ModelBody Type

Vin #

Plate NumberState

Owner's Name & Address:

Owner's Phone Number:

Driver's Name & Address:

Driver's Phone Number

Relation to Insured (Employee, Family, etc)

Date of Birth

Driver's License Number

State

Used with Permission  yes     no

Describe Damage

Estimate Amount

Where can Vehicle be seen?

When can Vehicle be seen?

Property Damaged:

Describe Property (If auto, year, make, model, plate #)

Other Veh/Property Insurance:    yes     no

Insurance Company or Agency Name and Policy Number

Owner's Name, Address and Phone Number:

Other Driver's Name, Address and Phone Number

(Check if same as owner)

Describe Damage

Estimate Amount

Where can Damage be seen?

Injured:

Name, Address and Phone Number

Pedestrian    Insured Vehicle    Other Vehicle

Age

Extent of Injury

Witness or Passengers:

Name, Address, and Phone Number:

Insured Vehicle    Other Vehicle

Other (specify)

Reported By