Automobile loss notice date of report



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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


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