                            AUTOMOBILE LOSS NOTICE                DATE ________

PRODUCER:  PHONE ___ ___ ____ EXT ____   MISCELLANEOUS INFORMATION: ___________
 _____________________________________   ______________________________________
 _____________________________________   COMPANY: _____________________________
 _____________________________________   POLICY NO: ___________________________
 _____________________________________   POLICY EFF DATE: _____________________
 _____________________________________   POLICY EXP DATE: _____________________
CODE: __________   SUBCODE: __________   DATE/TIME OF LOSS: ___________________
INSURED                                  PREVIOUSLY REPORTED:  ___ YES   ___ NO
NAME AND ADDRESS:                        RES PHONE ____________________________
 _____________________________________   BUS PHONE ____________________________
 _____________________________________   CONTACT: _____________________________
 _____________________________________   WHEN: ____________ WHERE: ____________
 _____________________________________   CONTACT RES PHONE: ___________________
LOSS                                     CONTACT BUS PHONE: ___________________
LOCATION OF ACCIDENT _________________   POLICE OR FIRE DEPT TO WHICH REPORTED:
 _____________________________________   ______________________________________
 _____________________________________   VIOLATIONS/CITATIONS _________________
DESCRIPTION OF ACCIDENT _______________________________________________________
 ______________________________________________________________________________
POLICY INFORMATION
BOD INJ _______ PROP DAM _______ SIN LIM _______ MED PAY _______ OTC DED ______
LOSS PAYEE _____________________________________________________ COL DED ______
OTHER COV & DEDUCTIBLES _______________________________________________________
INSURED VEHICLE
VEH NO __ YEAR,MAKE,MODEL ______________ VIN __________________ PLATE NO ______
OWNERS NAME & ADD _____________________________________________ PHONE _________
DRIVERS NAME & ADD ____________________________________________ PHONE _________
RELATION TO INSURED __________ DATE OF BIRTH ________ DR LIC NO _______________
PURPOSE OF USE _______________________________ USED WITH PERMISSION? _ YES _ NO
DESCRIBE DAMAGE ______________________________ ESTIMATE AMOUNT ________________
WHERE CAN VEHICLE BE SEEN ____________________ WHEN ___________________________
OTHER INSURANCE ON VEHICLE ____________________________________________________
PROPERTY DAMAGED
DESCRIBE PROPERTY ______________________________ OTHER VEH/PROP INS? _ YES _ NO
COMPANY OR AGENCY NAME & POLICY NO ____________________________________________
OWNERS NAME & ADD _____________________________________________ PHONE _________
DRIVERS NAME & ADD ____________________________________________ PHONE _________
DESCRIBE DAMAGE ______________________________ ESTIMATE AMOUNT ________________
WHERE CAN DAMAGE BE SEEN ______________________________________________________
INJURED
 NAME & ADDRESS            PHONE       PED INS  OTHER AGE   EXTENT OF INJURY
                                           VEH   VEH
 _______________________  ___________  ___ ___  _____ ___  ____________________
 _______________________  ___________  ___ ___  _____ ___  ____________________
WITNESSES OR PASSENGERS
 NAME & ADDRESS            PHONE       INS VEH  OTHER VEH        OTHER
 _______________________  ___________  _______  _________  ____________________
 _______________________  ___________  _______  _________  ____________________
REMARKS _______________________________________________________________________
REPORTED BY ___________________________   REPORTED TO _________________________
PRODUCER'S SIGNATURE ____________________________________________ DATE ________
