whitebird.gif (1468 bytes) AUTOMOBILE LOSS NOTICE Date (mm/dd/yy)  
  
Producer Company Effective Date

Date of Accident
Time     
AM PM

Phone number Policy Number Expiration Date
Insured
 Contact
Name and address of insured
 		Residence Phone
  		Name and address of insured:
Residence phone
 
Business Phone  
  		Business phone  
 
Loss
Location of accident (include city and state):
 		Authority contacted: Violations/citations:
Report #:
Description of accident:
Policy Information
Bodily injury (per person) Bodily injury (per accident) Property Damage Single Limit Medical Payment

Other coverage & deductibles (UM, no-fault, towing, etc)              

Loss Payee OTC Deductible Collision
Deductible
Insured Vehicle
Veh. # Make: Body Type:
Plate Number:
Year Model: V.I.N.:
State
Owner's name and address:
 Residence Phone (A/C, No.)
Business (A/C, No., Ext.)
Driver's name and address:

Check if same as owner 		Residence Phone (A/C, No.)
Business (A/C, No., Ext.)
Relation to insured (employee, family, etc.) Purpose of use Used with permission?
Yes
No 		Other insurance on vehicle Where can vehicle be seen? Estimate amount
Describe damage
Property Damaged
Describe property (if auto, year, make, model, plate #):
Other veh/prop ins?
Yes
No
Company or agency name:
Policy #:
Owner's name and address:
Residence Phone (A/C, No.)
Business (A/C, No., Ext.)
Other driver's name and address:

Check if same as owner 		Residence Phone (A/C, No.)
Business (A/C, No., Ext.)
Describe damage Estimate amount Where can damage be seen?
Injured
Name and Address Phone (A/C, No.) Ped Ins.
Veh. 		Oth.
Veh. 		Age Extent of injury
Witnesses or Passengers
Name and Address Phone (A/C, No.) Ins.
Veh. 		Oth.
Veh. 		Other (specify)
Remarks
Reported by
 Reported to
   
Applicable in Arizona:   For your protection, Arizona law requires the following statement to appear on this form. Any person who know­ing/y presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Applicable in Arkansas, Kentucky, Maine, Michigan, New Jersey, New Mexico, New York, Pennsylvania, and Virginia:   Any person who knowingly and with intent to defraud any insurance company or another person, files a state­ment of claim containing any materially false information, or conceals for the purpose of misleading, informa­tion concerning any fact material thereto, commits a fraudulent insurance act. which is a crime, subject to criminal prosecution and [NY: substantial civil penalties. In Maine and Virginia, insurance benefits may also be denied.
Applicable in California:   Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Applicable in Colorado:   It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Applicable in Florida and Idaho:   Any person who knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a State­ment of Claim Containing any False, Incomplete or Misleading information is Guilty of a Felony.*                               *       In Florida - Third Degree Felony
Applicable in Hawaii:   For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
Applicable in Indiana:   A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.
Applicable in Minnesota:   A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
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 New Hampshire:   Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
Applicable in Ohio:   Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Applicable in Oklahoma:   WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

      

Use Landscape option instead of Portrait when printing this form.