AUTOMOBILE LOSS NOTICE DATE (MM/DD/YYYY) AGENCY …

1 DATE (MM/DD/YYYY)PHONEAGENCYCOMPANYMISCELLANE OUS INFO (Site & location code)NAIC CODE:(A/C, No, Ext):POLICY NUMBERPOLICY TYPEREFERENCE NUMBERCAT #FAX(A/C, No):E-MAILADDRESS:PREVIOUSLYEFFECTIVE DATEEXPIRATION DATEDATE OF ACCIDENT AND TIMEREPORTEDCODE:SUB CODE:AGENCYCUSTOMER ID:WHEN TO CONTACT:NAME AND ADDRESSNAME AND ADDRESSSOC SEC # OR FEIN:WHERE TO CONTACTRESIDENCEBUSINESS PHONERESIDENCEBUSINESS PHONEPHONE (A/C, No):(A/C, No, Ext):PHONE (A/C, No):(A/C, No, Ext):CELLE-MAILCELLE-MAILPHONE (A/C, No):ADDRESS:PHONE (A/C, No):ADDRESS:AUTHORITYVIOLATIONS/CITATION SLOCATION OFCONTACTED:ACCIDENT(Include city & state)REPORT #:DESCRIPTION OFACCIDENT(Use separate sheet,if necessary)BODILY INJURYBODILY INJURYPROPERTY DAMAGESINGLE LIMITMEDICAL PAYMENTOTC DEDUCTIBLEOTHER COVERAGE & DEDUCTIBLES(Per Person)(Per Accident)(UM, no-fault, towing, etc) loss PAYEECOLLISION DEDUMBRELLA/LIMITS:CARRIER:EXCESSBODYVEH #YEARPLATE NUMBERSTATEMAKE:TYPE: :RESIDENCE PHONEOWNER S(A/C, No):NAME &BUSINESS PHONEADDRESS(A/C, No, Ext):DRIVER S NAMERESIDENCE PHONE& ADDRESS(A/C, No):BUSINESS PHONE(A/C, No, Ext):RELATION TO INSUREDUSED WITHDATE OF BIRTHDRIVER S LICENSE NUMBERSTATE(Employee, family, etc.)

2 PERMISSION?PURPOSEOF USEESTIMATE AMOUNTWHEN CAN VEH BE SEEN? OTHER INSURANCE ON VEHICLEWHERE CANDESCRIBEVEHICLEDAMAGEBE SEEN?COMPANY OROTHER VEH/PROP INS?DESCRIBE PROPERTYAGENCY NAME:(If auto, year, make,model, plate #)POLICY #:RESIDENCE PHONEOWNER S(A/C, No):NAME &BUSINESS PHONEADDRESS(A/C, No, Ext):OTHER DRIVER SRESIDENCE PHONENAME & ADDRESS(A/C, No):BUSINESS PHONE(A/C, No, Ext):ESTIMATE AMOUNTWHERE CANDESCRIBEDAMAGEDAMAGEBE SEEN?INS OTHNAME & ADDRESSPHONE (A/C, No)PEDAGEEXTENT OF INJURYVEH VEHINS OTHNAME & ADDRESSPHONE (A/C, No)OTHER (Specify)VEH VEHREMARKS (Includeadjuster assigned)REPORTED BYREPORTED TOSIGNATURE OF INSUREDSIGNATURE OF PRODUCERAMPMYESNOCONTACT INSUREDPERSIR/AGGRUMBRELLAEXCESSCLAIM/OC CDED(Check ifsame as owner)YESNOYESNO(Check ifsame as owner)YESNOINSUREDCONTACTLOSSPOLICY INFORMATIONINSURED VEHICLEPROPERTY DAMAGEDVEHICLE?INJUREDWITNESSES OR PASSENGERSNOTE: IMPORTANT STATE INFORMATION ON REVERSE SIDEACORD 2 (2006/02) ACORD CORPORATION 1988-2006 AUTOMOBILE loss NOTICE