home · programs · risk management · brokers · claims · news · company · contact

Automobile Loss Notice

Date of Accident

Time am pm

Policy Number

INSURED & CONTACT INFORMATION

Insured Name

Address

City, State Zip

Residence Phone

Business Phone

Contact Name

Contact Address

City, State Zip

Where to Contact

When to Contact

LOSS

Location of Accident

City, State

Authority Contacted

Report #

Description of
Accident

INSURED VEHICLE

Vehicle #	Year	Make	Model
Plate Number	State
V.I.N.

Current Location of Vehicle

Address

City, State

Owner's Name

Owner's Address

City, State

Driver's Name

Driver's Address

City, State

Description of
Damage

Estimate Amount $

PROPERTY DAMAGE

Description of
Property
This includes any other
involved auto's year,
make, model and plate #.

Other Veh/Prop Ins

Yes No

Company/Agency Name

Policy #

Owner's Name

Owner's Address

City, State

Owner's Phone

Driver's Name

Driver's Address

City, State

Description of
Damage

Estimate Amount $

INJURED

Name

Address

City, State

Phone

PED INS VEH OTH VEH

Extent of Injury

INJURED #2

Name

Address

City, State

Phone

PED INS VEH OTH VEH

Extent of Injury

INJURED #3

Name

Address

City, State

Phone

PED INS VEH OTH VEH

Extent of Injury

WITNESSES OR PASSENGERS

Name

Address

City, State

Phone

PED OTH VEH OTHER

Specify Other

SUBMITTED BY:

Name

Agency

Address

City, State

LOC Code

Date of Claim

Agent Notes

Phone

Fax

Email

IMPORTANT NOTICE: On-line claim reporting forms are submitted to Irwin Siegel Agency, Inc. If form is submitted after business hours or on a weekend, it will be sent to the carrier for processing the next business day (Monday through Friday 8:00 a.m. - 4:30p.m.)