11/20/2008 03:59:38 PM
70 Munroe Street Lynn, MA 01901 | Office: 781-599-2000 | Fax: 781-598-0170
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Report Auto Loss

Auto Notice of Claim

Insured Information

 Driver's Name  
 Email  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
 Driver License Number/State    Number   State
 Policy Owner's Name  
 Policy Number  

Loss Details

 Description of Accident. Include details of direction of travel for you and other vehicle and what you  were doing just prior to accident.
 Description of other type of loss. (theft, vandalism, etc.)
 Date of Loss    Time of Loss  
 Location of Loss  
 Authority Contacted    Report Number  
 Explain "Other Authority"  
 Were any citations issued?  
      If yes, what type  

Your Vehicle

 Year    Make    Model  
 Veh. License
 Number/State		    Vehicle ID Number  
 Describe damage to your vehicle.  
 Where is your vehicle now?  
 Are you able to drive your vehicle?  

Other Property or Vehicles Involved

 Describe Property damaged if other than another vehicle.
 Vehicle 1
 Year    Make    Model  
 Veh. License
 Number/State		    Vehicle ID Number  
 Describe damage to your  vehicle.  
 Where is your vehicle now?  
 Are you able to drive your vehicle?  
 Owner's Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
 Driver License Number/State    Number   State
 Policy Owner's Name  
 Policy Number  
 Vehicle 2
 Year    Make    Model  
 Veh. License
 Number/State		    Vehicle ID Number  
 Describe damage to your vehicle.  
 Where is your vehicle now?  
 Are you able to drive your vehicle?  
 Owner's Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
 Driver License Number/State    Number   State
 Policy Owner's Name  
 Policy Number  
 Vehicle 3
 Year    Make    Model  
 Veh. License
 Number/State		    Vehicle ID Number  
 Describe damage to your vehicle.  
 Where is your vehicle now?  
 Are you able to drive your vehicle?  
 Owner's Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
 Driver License Number/State    Number   State
 Policy Owner's Name  
 Policy Number  

Injuries

 1
  Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
 Describe Injury  
 2
  Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
 Describe Injury  
 3
 Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
 Describe Injury  
 4
 Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
 Describe Injury  

Witnesses

 1
  Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
 2
  Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
 3
  Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
 4
  Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 





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