Auto Claim/Loss

Please note that this form is for notification purposes and any changes will not be binding until you receive confirmation from us. If you do not hear from us in a reasonable amount of time,  ASSUME WE DID NOT GET THIS REQUEST.

I, the policy holder,  understand that filling out this form IS NOT binding. Changes ARE ONLY considered binding when I hear back from my agent indicating that they have received my request and will be processing it.
   
Policy Holder

Please be sure to complete all of the requested information so that your agent may contact you after receiving this notification.
Named  Insured::
Address:
Phone Numbers:  Work
Home
E-mail Address:

Details of Claim/Loss
Time & Date of Loss Time AM PM Date
Location:
(Number, Street, Intersection, etc.)
Detailed Description:
(use additional comments below if necessary)
Were the Police Notified? Yes  No
Department?:
Case Number?:
Were You Ticketed or at fault? Yes  No
If Yes, explain?

Vehicle Involved
Did you damage your vehicle? Yes     No
If Yes, explain:
Where is car located:
Which insured car  were you driving?
Yr.
Make:
Model:
License Plate #:
State:
Vin #:
Do we insure this car? Yes     No
If No, were you using it with permission? Yes     No
Please explain:
   

Other Party Information
If this claim involved another party, please provide us with as much information as possible
Name:

Address:
Phone: Work     
  Home
Automobile: Yr.    
  Make  
  Model
Driver's License #:    State
License Plate #:    State
Their Insurance Company:
Their Policy Number:
Describe damage to the other car:
Where is the car now?
   

Injuries, Witnesses, Etc.
If there were any Injuries, please describe:
Please list any Witnesses and/or Passengers: (Please include Name, Address and Phone #)
   

Additional Information
In the box below, please provide any additional information  you feel may be necessary 
for this Loss Notice form.