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Automobile Loss Notice

Please use the form below to notify us of any loss or damage to your automobile(s) insured through this company/agency. Please note that this form is for notification purposes only and does not constitute making an actual claim. One of our representatives will contact you shortly after receiving this notification.

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
(Box must be checked before request can be sent)

Step 1. Policy Holder Information:
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:
City:
State:
Zip Code:
Work Phone:
Home Phone:
Email:

Step 2. Time and Location of Accident
Time and Location of Accident
Time:
A.M. P.M.
Date:
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?

Step 3. Vehicle Information
Vehicle Information
Damage to Your Vehicle? Yes No
If Yes, describe:
Where Can Vehicle Be Seen?
Vehicle Year:
Make:
Model:
License Plate Number:
State:
Is This Your Car? Yes No
If No, were you using it with permission? Yes No
Please Explain:

Step 4. Other Driver Information
Other Driver Information
Name:
Address:
Work Phone:
Home Phone:
Vehicle Year:
Make:
Model:
Driver's License Number:
Driver's License State:
License Plate Number:
Licens Plate State:
Insurance Company:
Describe Damage to Other Vehicle:
Where Can Vehicle Be Seen?:
If There Were Any Injuries, Please Describe:
Please List Any Witnesses and/or Passengers:
(Please include name, address, and phone)

Step 5. Additional Information
Additional Information

Report Information
Reported By:
Title (if any):
Date:

Additional Comments

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

Please click on the "Submit" button to send your Loss Notice. One of our representatives will respond to your submission as soon as possible.
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