Identity theft is one
of the fastest growing crimes in the US today.
Identity thieves have developed a number of ways
to get your information - from the theft of your
purse to more elaborate internet-based scams. Once
they have your social security number, thieves can
establish credit in your name & incur hundreds or
even thousands of dollars in credit charges or
fraudulent loans. You may be unaware of these
charges until a collector seeks payment for the
bill you knew nothing about. Or you could be
denied a loan due to your credit report showing
defaults that were not yours.
You may not be able to
guard against all ways identity thieves can steal
your identity, but you can arm yourself with
protection that gives you the resources you need
to restore your good name and financial history in
the event of identity theft. Adding identity
theft to your homeowners policy is easy &
relatively inexpensive. Contact your insurance
agent today for details.
Automobile Loss Notification
Policy
Holder Information
You must include your phone number and/or email address
so that one of our representatives may contact you.
Full Name of Insured:
Address:
Phone #:
Work:
Home:
Email Address:
Time
and Location of Accident
Time & Date of Accident
Time
a.m.
p.m.
Date
Location of Accident:
(Number, Street, Intersection, city, etc.)
Description of the Accident:
Your
Vehicle Information
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:
Was There Damage Done to your vehicle?
Yes
No
If Yes, please describe:
Where can the vehicle be seen:
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 #)
Police
Notification
Were the Police Called?
Yes
No
What Authority?
Were You Ticketed?
Yes
No
If Yes, what for?
Report
Information
Reported by:
Title (if any):
Date:
Additional
Comments
Please provide any additional comments you feel appropriate for
this Loss Notice.
