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.
Contact your insurance carrier promptly to file an actual claim.

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)

Policy Holder  Information

Please be sure to supply your phone number and email address so that we may contact .

Name  Insured:*

Address:

City:

State:

Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont US Virgin Islands Washington Wisconsin West Virginia Wyoming

Zip Code:

Work Phone:

Home Phone:*

Email:*

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?

Vehicle Information

Damage to your vehicle?

 Yes No

If Yes, describe:

Where can the vehicle be seen?

Vehicle Year:

Make:

Model:

License plate  number:

State:

Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont US Virgin Islands Washington Wisconsin West Virginia Wyoming

Is this your car?

 Yes   No

If No, were you using it with permission?

 Yes   No

Please explain:

Other Driver Information

Name:

Address:

Work Phone:

Home Phone:

Vehicle Year:

Make:

Model:

Driver’s License number:

Driver’s License state:

Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont US Virgin Islands Washington Wisconsin West Virginia Wyoming

License plate number:

License plate state:

Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont US Virgin Islands Washington Wisconsin West Virginia Wyoming

Insurance Company:

Describe damage to other vehicle:

Where can the vehicle be seen:

Where there 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.

Please click on the "Submit” button to send your Loss Notice.
Contact your insurance carrier promptly to file an actual claim.

* Indicates required field