First Notice of Loss Form - Commercial Auto
To submit a New Assignment, please complete this form below and click on the Submit button. Please enter as much information as possible to expedite the investigation process. If you have any questions, please call (888)799-2919.
Required fields are in
bold
and noted with a *
* Reported By:
* Phone, (xxx) xxx-xxxx:
Insured Information
* Name: (First)
* (Last)
Policy Number
Address:
City:
State:
Zip Code:
* Primary Phone, (xxx) xxx-xxxx:
Alternate Phone:
Insured Driver of Vehicle
Name: (First)
(Last)
Address:
City:
State:
Zip Code:
Primary Phone, (xxx) xxx-xxxx:
Alternate Phone:
Driver's License:
Contact Instructions:
Insured Vehicle
* Year:
* Make:
* Model:
* Plate:
* Vin:
Are there additional vehicles?:
No
Yes
Insured Vehicle 2
* Year:
* Make:
* Model:
* Plate:
* Vin:
Are there additional vehicles?:
No
Yes
Insured Vehicle 3
* Year:
* Make:
* Model:
* Plate:
* Vin:
Are there additional vehicles?:
No
Yes
Insured Vehicle 4
* Year:
* Make:
* Model:
* Plate:
* Vin:
Loss Information
* Date of Loss (MM/DD/YYYY):
Time of Loss (xx:xx):
AM
PM
* Location of Accident:
City:
State:
* Description of Accident and Damages:
Cargo Damage:
Location of Vehicle:
Police Dept:
Report Number:
Officer Name / #:
Citations/Charges:
Claimant / Third Party Information
Driver
Name: (First)
(Last)
Insurance Company
Policy Number
Address:
City:
State:
Zip Code:
Primary Phone, (xxx) xxx-xxxx:
Alternate Phone:
Year:
Make:
Model:
Plate:
Additional Information:
Injuries
Name:
Phone, (xxx) xxx-xxxx:
Extent of Injury:
Name:
Phone, (xxx) xxx-xxxx:
Extent of Injury:
Witnesses and/or Passengers
Witness 1:
Name:
Address:
Res. Phone:
Bus. Phone:
Witness 2:
Name:
Address:
Res. Phone:
Bus. Phone:
Comments/Remarks/Instructions: