MOTOR VEHICLE LOSS NOTIFICATION
This form is to notify us of any loss or damage to your property insured through this 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. 

STATEMENT OF UNDERSTANDING
I understand that this form does not constitute an actual claim, but is a notification to our agency of an existing loss or claim, and may help expedite the claim process once submitted.
 
           I have read and agree with the above Statement of Understanding.
                            (Box must be checked before request can be sent)

                                          Policy Holder Information                                      
Please supply your phone numbers and email address
so that we may contact you after receiving your notification.

Name Insured:

Insured Address:
Phone #:  Work  Home Mobile
Email Address:  

Accident Time, Location and Damaged Description
Time: a.m.  p.m.                    Date of Damage:

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

Description of Accident:  

Police Notification

       Police Called?  Yes   No                               Ambulance Called?  Yes   No

Were You Ticked? 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 

Other Driver Name:  

Other Driver Address:  
Other Driver Phone:   Work:    Home:   Mobile:
Other Driver Automobile: Yr. Make: Model:  
Other Driver Driver's License #:   State 
Other Driver License Plate #:      State 

Other Driver Insurance Company: 

Describe Other Driver damage to   other vehicle:   

Other Driver 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 #)

Person Reporting Information

Reported by: 

Relationship to Property:

Date: 

                                                 Additional Comments                                       
Please give any additional comments you feel appropriate for this NOTIFICATION.