DiVirgilio Insurance Agency Inc. -- Automobile Loss Notice

AUTOMOBILE LOSS NOTICE Please use the form below to notify us of any loss or damage to your automobile(s) insured through this company/agency. Please note that this form is for notification purposes only and does not constitute making an actual claim. One of our representatives will contact you shortly after receiving this notification.

Disclaimer

I understand that this does not constitute an actual claim, but is rather a notification to my agent of an existing loss or claim, and may help expedite the claim process once I have filed.

	I have read and agree with the above disclaimer.
	(Box must be checked before request can be sent)

Policy Holder Information

Please be sure to supply your phone number and email address
so that we may contact you after receiving this notification.

Name of Insured:

Address:

Phone #: Work Home

Email:

Time and Location of Accident

Time & Date of Loss

Time a.m.
p.m. Date

Location of Accident:
(Number, Street, Intersection, etc.)

Description of Accident:

Police Notification

Were the Police Called? Yes No

What Authority?

Were You Ticketed? Yes No

If Yes, what for?

Your Vehicle Information

Damage to your vehicle? Yes No

If Yes, describe:

Where can car be seen:

What car were you driving? Yr. Make Model

License Plate #: State

Is this your car? Yes No

If No, were you using it with permission? Yes No Please explain below:

OTHER Driver Information

Name:

Address:

Phone: Work Home

Automobile: Yr. Make Model

Driver's License #: State

License Plate #: State

Insurance Company:

Describe damage to other vehicle:

Where can car be seen?

Injuries, Witnesses, Etc.

If there were any Injuries, please describe:

Please list any Witnesses and/or Passengers: (Please include Name, Address and Phone #)

Report Information

Reported by:

Title (if any):

Date:

Additional Comments

Please give any additional comments you feel appropriate for this Loss Notice.

Please click on the "Submit Form" button to send your Loss Notice.
One of our representatives will respond to your submission as soon as possible.

Policy Holder Information
Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.
Name of Insured:
Address:
Phone #:	Work Home
Email:

Police Notification
Were the Police Called?	Yes No
What Authority?
Were You Ticketed?	Yes No
If Yes, what for?

Your Vehicle Information
Damage to your vehicle?	Yes No
If Yes, describe:
Where can car be seen:
What car were you driving?	Yr. Make Model
License Plate #:	State
Is this your car?	Yes No
If No, were you using it with permission?	Yes No Please explain below:

OTHER Driver Information
Name:
Address:
Phone:	Work Home
Automobile:	Yr. Make Model
Driver's License #:	State
License Plate #:	State
Insurance Company:
Describe damage to other vehicle:
Where can car be seen?

Injuries, Witnesses, Etc.
If there were any Injuries, please describe:
Please list any Witnesses and/or Passengers:	(Please include Name, Address and Phone #)