Automobile Loss Report
Insurance Company:
*
Policy #:
*
Expiry Date:
*
Named Insured
Name:
*
Address:
*
City:
*
Postal Code:
*
Home Phone:
*
Work Phone:
Cell:
Fax:
Contact Person
Same as Insured:
yes
Name:
Relationship:
Home Phone:
Work Phone:
Cell:
Fax:
Driver Information
Same as Insured:
yes
Name:
Relationship:
Address:
City:
Postal Code:
Home Phone:
Work Phone:
Cell:
Fax:
Is the driver listed on the policy:
*
Yes
No
If not listed, why.:
Used with Permission?:
yes
Driver's License #:
Purpose of Use:
Insured Vehicle Information
Make:
*
Model:
*
Year:
*
VIN#:
*
Plate #:
*
# Of Occupants:
*
Is Vehicle Drivable?:
*
Yes
No
If not where was it towed?:
Where can the vehicle be seen?:
When can the vehicle be seen?
Date:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2009
2010
2011
2012
2013
Time:
hour
1
2
3
4
5
6
7
8
9
10
11
12
:
minute
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
am
pm
Any Liens and/or Leases on this Vehicle:
*
yes
no
If so, name:
Area of Damage:
*
Amount of Damage:
*
Details of Loss
Date of Loss:
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2009
2010
2011
2012
2013
Time of Loss:
*
hour
1
2
3
4
5
6
7
8
9
10
11
12
:
minute
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
am
pm
Date Reported:
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2009
2010
2011
2012
2013
Time Reported:
*
hour
1
2
3
4
5
6
7
8
9
10
11
12
:
minute
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
am
pm
Reported By:
*
Loss Location:
*
Weather:
*
Road Condition:
*
Insured Speed:
*
Insured Direction:
*
Insured Seat belt:
*
yes
Type of Signal:
*
Third Party Speed:
Third Party Direction:
% of Fault / Insured:
Description of loss and Damage:
*
Authority Report Information
Police / Fire Report:
select...
Fire
Police
Municipality:
Division:
Officer's Name:
Accident #:
Badge #:
Contact Number:
Charges Laid?:
charges_laid
If so, what kind:
Against Whom:
select...
Insured
Third Party
Injured Party Information
Injured Party:
yes
Number Injured:
Name:
Address:
City:
Postal Code:
Home Phone:
Work Phone:
Cell:
Fax:
Nature of Injury:
Hospitalized:
yes
Name / Address of Facility:
Third Party Information
Third Party Owner Information
Name:
Address:
City:
Postal Code:
Home Phone:
Work Phone:
Cell:
Fax:
Insurer:
Policy #:
Claim #:
Phone #:
Adjuster's Name:
Third Party Driver Information
Same as Owner:
yes
Name:
Address:
City:
Postal Code:
Home Phone:
Work Phone:
Cell:
Fax:
Driver's License #:
Third Party Vehicle Information
Make:
Model:
Year:
VIN#:
Plate #:
Number of Occupants:
Location of Damages:
Witness Information
Name:
Address:
City:
Postal Code:
Home Phone:
Work Phone:
Cell:
Fax:
Notes:
Remarks:
