Auto Loss Reporting Form

    Date of Loss:

    Time of Loss:

    Police Department:

    Police Report #:

    Description of Loss:

    Insured Driver's Information:

    Name:

    Phone #:

    Insured Vehicle:

    Year:

    Make:

    VIN #:

    Damages:

    Location of Vehicle:

    Injuries:

    Any Injuries?:

    Yes (if yes list below)No

    Description of Injuries:

    Name:

    Insured VehicleOther VehiclePedestrian

    Name:

    Insured VehicleOther VehiclePedestrian

    Other Driver Information:

    Driver's Name:

    Owner's Name:

    Yr / Make of Vehicle:

    Insurance Carrier:

    Policy #: