Dan Hurley Insurance

Independent Insurance Agent

Automobile Loss Notice

AUTOMOBILE LOSS NOTICE DATE(MM/DD/YY)
PRODUCER PRODUCER PHONE:
 MISC INFO
CODE:        
SUBCODE: 		COMPANY: POLICY NO:
POLICY EFF. DATE: POLICY EXP. DATE: DATE&TIME OF LOSS: PREVIOUSLY REPORTED(Y OR N):

Insured

NAME :

ADDRESS:

 INSURED'S RESIDENCE PHONE: INSURED'S BUSINESS PHONE:
PERSON TO CONTACT: WHERE TO CONTACT: WHEN:
CONTACT'S RESIDENCE PHONE: CONTACT'S BUSINESS PHONE:

Loss
LOCATION OF ACCIDENT(city & state):
AUTHORITY CONTACTED & REPORT NO: VIOLATIONS/CITATIONS:
DESCRIPTION OF ACCIDENT:   

Insured Vehicle
VEH. NO: YEAR,MAKE,MODEL: VEHICLE IDENTIFICATION: PLATE NO.:
OWNER'S NAME AND ADDRESS: PHONE:
DRIVER'S NAME&ADDRESS:
DRIVER SAME AS OWNER: RESIDENCE PHONE: BUSINESS PHONE:
RELATION TO INSURED: DATE OF BIRTH: DRIVER'S LICENSE NUMBER: PURPOSE OF USE: USED WITH PERMISSION?:
DESCRIBE DAMAGE
 EST. AMOUNT: WHERE CAN VEHICLE BE SEEN?: WHEN?: OTHER INSURANCE ON VEHICLE:

Other Vehicle
DESCRIBE PROPERTY: OTHER VEH/PROP. INS?: COMPANY & POLICY NO.:
OWNER'S NAME & ADDRESS: BUSINESS PHONE: RESIDENCE PHONE:
OTHER DRIVER'S NAME & ADDRESS: RESIDENCE PHONE: BUSINESS PHONE:
DESCRIBE DAMAGE: EST. AMOUNT: WHERE CAN DAMAGE BE SEEN?:

Injured
NAME & ADDRESS: PHONE: PED.: INS. VEH.: OTHER VEH.: AGE: EXTENT OF INJURY:

Witness
NAME & ADDRESS: PHONE: INS. VEH.: OTHER VEH.: OTHER:

 

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