Automobile Loss Notification (Auto Claim)

(315) 797-8080
136 Clinton Road (Rt 12b), New Hartford, NY, 13413

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Please use the form below to notify our agency about a claim towards your automobile policy. You will be contacted shortly by one of our qualified representatives. This does not constitute a claim until confirmed by one of our agents.

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:
	Cell: Other:
Email Address:

Time and Location of Accident

Time and Location 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:
Is the vehicle drivable?	Yes No

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.

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(315) 797-8080
136 Clinton Road (Rt 12b), New Hartford, NY, 13413