818.769.1809
AUTOMOBILE LOSS NOTICE
Please use the form below to notify our agency about a claim towards your automobile policy. You will contacted shortly by one of our qualified representatives. This does not constitute a cliam until confirmed by one of our agents.
Policy Holder Information
*Required field are in bold
You must include your phone number and email address
so that one of our representatives may contact you.
Full Name of Insured:
Address:
Phone #:
Work
Home
Email Address:
Insurance Policy #:
Time and Location of Accident
Time & Date of Accident
Time
a.m.
p.m.
Date
Location of Accident:
(Number, Street, Intersection, city, etc.)
Description of the Accident:
Your Vehicle Information
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:
Was There Damage Done to your vehicle?
Yes
No
If Yes, please describe:
Where can the vehicle be seen:
OTHER Driver Information
Name:
Address:
Phone:
Work
Home
Automobile:
Yr.
Make
Model
Driver's License #:
State
License Plate #:
State
Insurance Company:
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 #)
Police Notification
Were the Police Called?
Yes
No
What Authority?
Were You Ticketed?
Yes
No
If Yes, what for?
Report Information
Reported by:
Title (if any):
Date:
Additional Comments
Please give any additional comments you feel appropriate for this Loss Notice.
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