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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