Loss Control Center Video Library Claim Notification Forms and Loss Notices
Automobile Loss Notice
All fields are required.
Policy Number    
Person Insured
Name    
Address    
City    
State    
Contact Person    
Accident Information
Date of Accident mm/dd/yyyy     
Time of Accident  hh:mm AM/PM       
Location of Accident (street, road, city, state)
 
Notified Policy
(leave blank if none)
Description  
Insured Vehicle
Year    
Make    
Model    
ID#    
VIN    
Vehicle Damage
 
Estimate Amount of Damage    
Where can vehicle be seen?    
Driver Information
Name    
Address    
City    
State    
Business Phone  xxx-xxx-xxxx  
Home Phone  xxx-xxx-xxxx  
Employee    
Date of Birth  mm/dd/yyyy     
Other Vehicle - Owner
Name    
Address    
City    
State    
Phone  xxx-xxx-xxxx  
Other Vehicle
Description
 
Persons Involved
Was anyone injured (Y/N) Who?
 
Passengers in other vehicle (names & phones)  
Witnesses (names and phones)
 
 
Remarks
 
Person making report (name and phone)
 

3905 South 148th Street, Suite 100                                              Omaha, NE 68144                                                                                            800-642-8572