Automobile

Automobile Loss Claim Form

*Required

Agent and Policy Information Section

Agent:
Policy Number:

Insured Information - Section

Insured Name:*	*
Insured Address:

Home Phone:
Work Phone:
Cell Phone:
Email Address:	**

Contact Information (if different from named insured)

Name:
Address:
Home Phone:
Business Phone:
Cell Phone:
Email Address:	*

Accident Information Section

Date of Accident:*	** mm/dd/yyyy
Time Of Accident:*	AM PM

Location Of Accident:*

*

Is There a Police Report:

Yes

No

Which Police Department was contacted?

Violations/Tickets Issued

Description of Accident:*

*

Insured Vehicle Section

Insured Vehicle - Year:

Insured Vehicle - Make:

Insured Vehicle - Model:

*

Insured Vehicle - VIN:

Insured Vehicle - License Plate Number:

State of License Plate:*

*

Owners Name:

Owners Address:

Owners Home Phone:

Owners Business Phone:

Drivers Name:

same as owner

Drivers Address:

Drivers Home Phone:

Drivers Business Phone:

Drivers Relation to Insured:

Drivers Date of Birth:

mm/dd/yyyy

Drivers License Number:

State of Drivers License:

Purpose of Use:

Used With Permission:

Yes

No

Description of Damage to Vehicle:

Where can the vehicle be seen?:

Other Property Damage Section (Insured vehicle not included)

Property Type:

If Other, please describe:

*

Year of Vehicle:

Make of Vehicle:

Model of Vehicle:

Plate Number of Damaged Vehicle:

Other Vehicle/Property Insurance:

Yes

No

Company or Agency Name:

Policy Number:

Name of Owner:*

*

Address of Owner:*

*

Home Phone:

Business Phone:

Cell Phone:

Email Address:

*

Other Drivers name and address:

* same as owner

Home Phone:

Business Phone:

Description of Damage:

Where can the damage be seen?:

Injury Section

Injured Party 1

Injured Party's Name:

Injured Party's Address:

Phone Number:

Pedestrian

Insured Vehicle

Other Vehicle

Age:

Extent of Injury:

Injured Party 2

Injured Party's Name:

Injured Party's Address:

Phone Number:

Pedestrian

Insured Vehicle

Other Vehicle

Age:

Extent of Injury:

Witness Section

Witness 1

Witness/Passenger name and address:

Phone Number:

Insured Vehicle

Other Vehicle

Other:

Witness 2

Witness/Passenger name and address:

Phone Number:

Insured Vehicle

Other Vehicle

Other:

Reporting Information Section

Your Name:*

*

If not reported by our insured, complete the information below

Your Phone Number:
Your relationship to insured:
Additional Comments if Any:

(New Jersey) Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. (Maryland) Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. (Pennsylvania) Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.