CSIO Automobile Loss Notice - CoreService

1 Automobile loss NOTICEINSURERBROKERCODEPHONEPOLICY NUMBERCLIENT IDREPORT DATE (YYYY/MM/DD)INSUREDADDRESSBUS. #RES. #PREVIOUSLY REPORTEDYESNOIF YES, DATE REPORTEDREPORTED BYTOADJUSTER ASSIGNEDTYPENAME AND ADDRESSPHONE AND WHEN TO CONTACTTYPENAME AND ADDRESSPHONE AND WHEN TO CONTACTTYPENAME AND ADDRESSPHONE AND WHEN TO CONTACTLANGUAGELANGUAGELANGUAGEADJUSTER CONTACTSS pecify type: A = Insured B = Other insured driver C = Passenger D = Third party driver E = Other party driver F = Witness2. loss INFORMATIONCSIO AUTO loss (10/96)DATE (YYYY/MM/DD)CAUSE OF LOSSTYPE OF loss :THIRD PARTY BITHIRD PARTY PD$$$$$ACC. BENEFITSCOLLISION / APCOMP / SPESTIMATED AMT:LOCATION OF loss - INCLUDING STREET ADDRESS, CITY, PROVINCE AND STREET NAMES OF ANY APPLICABLE INTERSECTIONDESCRIPTION OF loss AND DAMAGETYPENAME AND ADDRESSPHONE OF INJURYAGETYPEYEARYEARMODELMODELBODY TYPEBODY TYPEVINVINWHERE AND WHEN DAMAGE CAN BE SEENWHERE AND WHEN DAMAGE CAN BE SEENPLATE $ESTIMATE $DRIVABLE?

2 DRIVABLE?YESYESNONOOWNER S NAME, ADDRESS AND PHONE NO. IF NOT THE INSUREDOWNER S NAME, ADDRESS AND PHONE NO. IF DIFFERENT FROM DRIVERDRIVER NAME AND ADDRESSDRIVER NAME AND ADDRESSDESCRIBE ANY OTHER DAMAGE TO PROPERTY, INCLUDING THE OWNER S NAME, ADDRESS AND PHONE NUMBER, ESTIMATED AMOUNT, WHERE AND WHEN THE DAMAGE CAN BE SEEN AND THE DETAILS OFOTHER INSURANCE ON THE PROPERTYFOR POLICY # SHOWN ABOVEEFF. DATEEXP. DATEFORM(S)ENDORSEMENT, LIMITS AND DEDUCTIBLES#PHYSICAL DAMAGEPHYSICAL DAMAGE##$COMPSPCOLLAP$$DED. $DED. $DED. $SINGLE LIMITBODILY INJURYPER PERSONBODILY INJURYPER ACCIDENTTHIRD PARTYPROPERTY DAMAGEACCIDENTBENEFITS$$$$$$$DETAILS OF ADDITIONAL COVERAGES, FLOATERS OR EXCLUSIONS AFFECTING THE LOSSNAME AND ADDRESSNATURE OF INTERESTPOLICY DATEINSUREREXP.

3 DATENAME AND ADDRESSNATURE OF INTERESTPOLICY DATEINSUREREXP. DATENAME AND ADDRESSNATURE OF INTERESTPOLICY DATEINSUREREXP. DATEBUS. #BUS. #RES. #RES. #POLICY OF USEDRIV. LIC. #DRIV. LIC. # TO OF BIRTHUSED WITH PERMISSION?YESNONAME AND ADDRESSPHONE OF INJURYAGEPOLICE DEPARTMENT REPORTED TOMUNICIPALITYDIVISION S NAMEBADGE INJURIESS pecify type of claimant A = Insured driver B = Insured passenger C = Third party driver or passenger D = Pedestrian4. INSURED VEHICLE AND DRIVER5. THIRD PARTY VEHICLE AND DRIVER(Use another form if more than one vehicle is involved.)6. OTHER PROPERTY DAMAGE7. POLICY AND COVERAGE INFORMATIONADDITIONAL INTERESTSOTHER INSURANCE2000, Centre for Study of Insurance Operations.

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