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Automobile Loss Notice

Insured
Name & Address:
SOC SEC # or Fein:
E-mail address:
Residence Phone:
Business Phone:
Contact
Contact Insured
Name & Address:
When to contact:
Where to contact:
E-mail address:
Residence Phone:
Business Phone:
Loss
Location of Accident (include city & state):
Date of Accident & Time: :
Authority contacted:
Report #:
Violations/Citations:
Description of accident:
Use separate sheet, if necessary
Insured Vehicle
Vehicle #:
Year:
Make:
Model:
Body Type:
V.I.N.:
Plate Number:
State:

 
Owner's Name:
Address:
Residence Phone:
Business Phone:

Same as owner
Driver's Name:
Address:
Residence Phone:
Business Phone:

Relation to Insured (Employee, family, etc.):
Date of Birth:
Driver's License Number:
State:
Purpose of Use:
Used with permission? Yes No
Describe Damage:
Estimate Amount:
Where can vehicle be seen:
When can vehicle be seen:
Other insurance on vehicle:
Property Damaged
Vehicle? Yes No
Describe Property:
If auto, year, make, model, plate #
Other Veh/Prop Ins: Yes No
Company or Agency Name:
Policy #:

 
Owner's Name:
Address:
Residence Phone:
Business Phone:

Same as owner
Driver's Name:
Address:
Residence Phone:
Business Phone:

Describe Damage:
Estimate Amount:
Where can damage be seen:
Injured
Name & Address Phone (A/C, No) PED Ins
Veh
Oth
Veh
Age Extent of Injury
Witnesses or Passengers
Name & Address Phone (A/C, No) Ins
Veh
Oth
Veh
Other (Specify)
Remarks:
(Include adjuster assigned)

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Baker, Jim
Casey, Bryan
Casey, Dod
Cohen, Neal
Cohn, Allan
Cook Kline, Stacia
Fox, Sue
Kibbe, Gene
Krell, Amir
Odekunle, Funlola
Orodeckis, Ed
Orodeckis, Eric
Orodeckis, Patrick
Quingert, Jack
Rosenberg, Henry
Rosenberg, Stephen
Rosenberg, Stewart H.
Schaftel, James
Stavrakas, Spyros
Summerfield, Alan
Summerfield, AAI, Jordan
Sutton(Kwiatowski), Tracy


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