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. One of our representatives will contact you shortly after receiving this notification.

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Policy Holder Information
Name Insured:
Phone #: Work     Home

Time and Location of Accident
Time & Date of Loss
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?

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
Is this your car? Yes     No
If No, were you using it
with permission?

OTHER Driver Information
Phone: Work     Home
Automobile: Yr.   Make   Model
Driver's License #:   State
License Plate #:   State
Describe damage
to other vehicle:
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 #)

Report Information
Reported by:


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