Personal Auto

First Notice of Loss Assignment Form – 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 (800)285-2524.
Required fields are in bold and noted with a *

Client Information

Name of person reporting claim:*

Contact Phone, (xxx) xxx-xxxx:*

You are submitting this claim as (policyholder, claim against policyholder, ect.):*

Loss Information

Date of Loss (MM/DD/YYYY):*

Time of Loss (xx:xx):
:
HH

MM

Facts of Accident:*

Police Department:

Police Report Number or Case Number:

Location of Loss: Intersection/Street/Freeway:

City:

State:

PolicyHolder

Policyholder's Name:

First

Last

Policy Number:

Policyholder's Street Address:

Street Address

City

State / Province / Region

ZIP / Postal Code

Contact Phone, (xxx) xxx-xxxx:

Ext.:

Additional Contact Phone:

Contact Email:

What is the best time to contact?

PolicyHolder's Vehicle

Name of driver involved in incident:

First

Last

What is the relationship of the driver to the policyholder (e.g., same, spouse, friend):

Vehicle Year:

Vehicle Make:

Vehicle Model:

License Number:

Describe Vehicle Damage:

Is the vehicle drivable?

Where is the vehicle currently located?

Please list the names of any passengers and their contact information:

Other Vehicle Involved in Accident

Driver's Name:

First

Last

Who is the vehicle's owner?

Street Address

City

State / Province / Region

ZIP / Postal Code

Contact Phone, (xxx) xxx-xxxx:

Ext.:

Additional Contact Phone:

What is the best time to contact?

Contact Email:

Vehicle Year:

Vehicle Make:

Vehicle Model:

License Plate Number:

Describe Vehicle Damage:

Is the vehicle drivable?

Where is the vehicle currently located?

Please list the names of any passengers and their contact information:

Please provide the insurance company for this vehicle:

Please provide the policy or claim#:

Were additional vehicles involved?:

Property Damaged

Please describe any other property damaged (e.g. mailbox, street sign, ect.):

Injured Persons

Please list the names, injury and contact information for all injured persons:

Witnesses

Please list the names, addresses, and phone numbers for all witnesses: