Automobile Loss Notice - Interline Risk Services

Date of Accident*

Time of Day

:

Address of Accident*

Street Address City State / Province / Region ZIP / Postal Code Country

Description of Accident*

Police or Fire Department to which you reported

Report, Case or File Number

Violations or Citations Issued

Property Damage to the Other Vehicle

Make*

Model*

Body Type

Year*

Vehicle Identification Number

Owner's Name*

Owner's Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Residential Phone*

Business Phone

Was the Owner Driving?

Yes

No

Driver's Name

Driver's Address

Street Address City State / Province / Region ZIP / Postal Code Country

Driver's Phone Number

Damage/Estimate

Property Damage to the Insured's (our) Vehicle

Make*

Model*

Body Type*

Year*

VIN*

Owner's Name*

Owner's Address

Street Address City State / Province / Region ZIP / Postal Code Country

Owner's Phone*

Business Phone*

Was Someone Else Driving?*

Yes

No

Driver's Name / Relation to Insured*

Driver's Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Driver's Phone*

Driver's Date of Birth*

Driver's License Number*

State Issued*

State / Province / Region

Purpose of Vehicle Use*

Used with Permission?*

Yes

No

Damage

Describe Accident

Where is the Vehicle Now?

Phone for Location

Other Information

Injuries

Are there any injuries?*

Yes

No

Name

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Description of Injury

Witnesses

Passenger/Witness Name

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Remarks

Print Name*

Title*

Date*

Email

This field is for validation purposes and should be left unchanged.