Auto Claim/Loss

Policy Change Disclaimer
Please note that this submission is a request. It is important to include as much information as possible in order to process your request. Insurance coverage changes and new coverage are not effective and are not bound until your receive confirmation from us.
   
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 a.m. p.m. 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.


 

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