Policy Number

Policy Date From

TO

Policy Date

Producer Name

INSURED INFORMATION

Name

Address

Street Address City ZIP / Postal Code

State

Primary Phone

Alternate Phone

Email Address

CONTACT INFORMATION

If Different from Insured

Name

Address

Street Address City ZIP / Postal Code

State

Primary Phone

Alternate Phone

Email Address

LOSS INFORMATION

Date of Accident

Time of Accident

: HH

MM

Reported by

Location of Accident

Authority Contacted

Report #

Violations/Citations

Description of Accident

INSURED VEHICLE

Vehicle #

Year

Make

Model

Body Type

V.I.N.

Plate #

State

Owner’s Name

Owner's Address

Street Address

Mobile Number

Alternate Number

Driver’s Name

Driver's Address

Same as previous

Street Address

Mobile Number

Alternate Number

Relation to Insured

Date of Birth

Driver’s License #

State

Purpose of Use

Used with Permission?

YES
NO

Describe Damage

Estimate Amount

Where & When Can Vehicle Be Seen?

Other Insurance on Vehicle

PROPERTY DAMAGED

Vehicle?

YES
NO

Describe Property: (if auto: year, make, model, plate #)

Other Vehicle/Property Insurance

YES
NO

Company/Agency Name

Policy #

Owner’s Name

Property Owner's Address

Street Address

Phone Number

Alternate Number

Other driver’s Name & Address

Same as vehicle owner

Street Address

Phone Number

Alternate Number

Describe Damage

Estimate Amount

Email

INJURED

Name

Address

Phone Number

Pedestrian
Insured Vehicle
Other Vehicle

Extent of Injury

Name

Address

Phone Number

Pedestrian
Insured Vehicle
Other Vehicle

Extent of Injury

WITNESSES OR PASSENGER

Name

Address

Phone Number

Insured Vehicle
Other Vehicle

Other (specify)

Name

Address

Phone Number

Insured Vehicle
Other Vehicle

Other (specify)

Remarks

APPLICABLE IN CALIFORNIA

PRIVACY NOTICE: Your privacy is important to us. To learn more about the categories of personal information we collect through this form, and how we use this information, please visit our privacy policy here.

For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Regarding any Liability insurance claim: For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Regarding any claim arising from the theft of an insured vehicle: False representations made on the signed claim form by the insured subject the insured to a penalty of perjury.

APPLICABLE IN NEVADA

Pursuant to NRS §686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete, or misleading information concerning a material fact is guilty of a felony.

APPLICABLE IN WASHINGTON

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

APPLICABLE IN ARIZONA

For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

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Automobile Loss Notice

TO

INSURED INFORMATION

CONTACT INFORMATION

LOSS INFORMATION

INSURED VEHICLE

PROPERTY DAMAGED

INJURED

WITNESSES OR PASSENGER

APPLICABLE IN CALIFORNIA

APPLICABLE IN NEVADA

APPLICABLE IN WASHINGTON

APPLICABLE IN ARIZONA