ACORD AUTOMOBILE LOSS NOTICE OP ID



|AUTOMOBILE LOSS NOTICE |DATE OF REPORT |

| |      |

|PRODUCER PHONE |COMPANY |MISCELLANEOUS INFO (site & Location code) |

| | |      |

| |POLICY NUMBER |TOWNSHIP REFERENCE NUMBER |CAT# |

| |JIF/MEL |      |      |

|CODE |SUB CODE |EFFECTIVE DATE |

|      |      | |

| | |      |

|RESIDENCE PHONE |BUSINESS PHONE |RESIDENCE PHONE |BUSINESS PHONE |WHEN TO CONTACT |

|(A/C. NO.) |(A/C. NO. EXT) |(A/C. NO.) |(A/C. NO. EXT) |      |

|      |      |      |      | |

LOSS

|LOCATION OF ACCIDENT (Include city & state) |AUTHORITY       |VIOLATIONS/CITATIONS |

|      |CONTACTED: |      |

|      | |      |

|      | |      |

| |REPORT NO.       | |

|DESCRIPTION OF ACCIDENT (Use separate sheet, if necessary) |

|      |

INSURED VEHICLE

|VEH # |YEAR |MAKE |      |

|      |      | | |

| | |BUSINESS PHONE (A/C NO EXT) |      |

|DRIVER’S NAME & ADDRESS |      |RESIDENCE PHONE (A/C NO EXT) |      |

|(Check if same as owner) |      | | |

| | |BUSINESS PHONE (A/C NO EXT) |      |

|RELATION TO INSURED |DATE OF BIRTH |DRIVER’S LICENSE NO. |STATE |PURPOSE OF USE |

|      |      |      |      |      |

PROPERTY DAMAGE

|DESCRIBE PROPERTY (If auto, year, make, model, plate #) |OTHER VEH/PROP INS? |COMPANY OR AGENCY NAME |      |

|      |YES NO | | |

| | |POLICY # |      |

|OWNER’S NAME & |      |RESIDENCE PHONE (A/C NO EXT) |      |

|ADDRESS | | | |

| | |BUSINESS PHONE (A/C NO EXT) |      |

|OTHER DRIVER’S NAME & ADDRESS (Check if |      |RESIDENCE PHONE (A/C NO EXT) |      |

|same as owner) |      | | |

| | |BUSINESS PHONE (A/C NO EXT) |      |

|DESCRIBE DAMAGE       |ESTIMATE AMOUNT |WHERE CAN DAMAGE BE SEEN?       |

| |      | |

INJURED

|NAME & ADDRESS |PHONE (A/C, NO) |PED |INS |OTH |

| | | |VEH |VEH |

|      |      | | |      |

|      |      | | |      |

|REMARKS       |

|REPORTED BY |REPORTED TO |

|      | |

ACORD 2 (1/97)

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