Automobile loss notice date of report
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JIF/MEL
AUTOMOBILE
LOSS NOTICE
DATE OF REPORT
PRODUCER PHONE
COMPANY
MISCELLANEOUS INFO (site & Location code)
POLICY NUMBER
JIF/MEL
TOWNSHIP REFERENCE NUMBER
CAT#
CODE
SUB CODE
EFFECTIVE DATE
EXPIRATION DATE
DATE
OF ACCIDENT
PREVIOUSLY REPORTED
YES
NO
AGENCY CUSTOMER ID
BERNA-7
TIME
OF ACCIDENT
AM
PM
INSURED
NAME AND ADDRESS SOC. SEC#
NAME AND ADDRESS WHO
TO CONTACT
WHERE TO CONTACT
RESIDENCE PHONE
(A/C. NO.)
BUSINESS PHONE
(A/C. NO. EXT)
RESIDENCE PHONE
(A/C. NO.)
BUSINESS PHONE
(A/C. NO. EXT)
WHEN TO CONTACT
LOSS
LOCATION OF ACCIDENT (Include city & state)
AUTHORITY
CONTACTED:
VIOLATIONS/CITATIONS
REPORT NO.
DESCRIPTION OF ACCIDENT (Use separate sheet, if necessary)
INSURED VEHICLE
VEH #
YEAR
MAKE
BODY TYPE
PLATE NUMBER
STATE
MODEL
VIN
OWNER’S NAME & ADDRESS
RESIDENCE PHONE (A/C NO EXT)
BUSINESS PHONE (A/C NO EXT)
DRIVER’S NAME &
ADDRESS
(Check if same as owner)
RESIDENCE PHONE (A/C NO EXT)
BUSINESS PHONE (A/C NO EXT)
RELATION TO INSURED
DATE OF BIRTH
DRIVER’S LICENSE NO.
STATE
PURPOSE OF USE
USED WITH PERMISSION?
Yes
No
DESCRIBE DAMAGE
ESTIMATE AMT
WHERE CAN VEH BE SEEN?
WHEN CAN VEH BE SEEN?
OTHER INSURANCE ON VEH?
PROPERTY
DAMAGE
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 (A/C NO EXT)
BUSINESS PHONE (A/C NO EXT)
OTHER DRIVER’S NAME & ADDRESS
(Check if same as owner)
RESIDENCE PHONE (A/C NO EXT)
BUSINESS PHONE (A/C NO EXT)
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
WITNESS OR PASSENGERS
NAME & ADDRESS
PHONE (A/C, NO)
INS
VEH
OTH
VEH
OTHER (Specify)
REMARKS
REPORTED BY
REPORTED TO
ACORD 2 (1/97)
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