Disclaimer

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.

 

	I have read and agree with the above disclaimer.
	(Box must be checked before request can be sent)

Policy Holder Information

Please be sure to supply your phone number and email address
so that we may contact you after receiving this notification.

Name Insured:

Address:

Phone #:

Work      Home

Email:

Time and Location of Accident

Time & Date of Loss

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

Description of Accident:

Police Notification

Were the Police Called?

Yes     No

What Authority?

Were You Ticketed?

Yes     No

If Yes, what for?

Your Vehicle Information

Damage to your vehicle?

Yes     No

If Yes, describe:

Where can car be seen:

What car were you driving?

Yr.    Make    Model

License Plate #:

   State

Is this your car?

Yes     No

If No, were you using it with permission?

Yes     No     Please explain below:

OTHER Driver Information

Name:

Address:

Phone:

Work      Home

Automobile:

Yr.    Make    Model

Driver's License #:

   State

License Plate #:

   State

Insurance Company:

Describe damage to other vehicle:

Where can car 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 #)

Report Information

Reported by:

Title (if any):

Date:

Additional Comments

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