INJURY TO PEOPLE: TELEPHONE IMMEDIATELY if possibility of injury exists (No matter how minor). DAMAGE TO PROPERTY: IF SERIOUS, (Vehicle Disabled) TELEPHONE IMMEDIATELY OTHER: If vehicle is insured for collision and disabled due to damage - TELEPHONE IMMEDIATELY. COMMONWEALTH OF VIRGINIA Automobile Loss Notice Form If claim is under Comprehensive, Fire or Theft, only sections marked with * need to be completed DO NOT DISCUSS ACCIDENT WITH ANY ONE EXCEPT COMPANY REPRESENTATIVE OR POLICE. *POLICY- HOLDER NAME ADDRESS: STREET CITY STATE ZIP CODE POLICY NUMBER PHONE NUMBER C-900093 James Madison University 1041 S. Main St., MSC 5725 Harrisonburg VA 22807 (540) 568-7701 *TIME AND PLACE OF ACCIDENT DATE OF ACCIDENT HOUR A.M. P.M. LOCATION STREET OR HIGHWAY CITY COUNTY STATE STATE AGENCY OR COMMUNITY SERVICESBOARD as insureds USE ONLYMAKE OF AUTO NAME OF OWNER OR LEASING COMPANY NAME OF DRIVER DRIVER'S DATE OF BIRTH WAS AUTO BEING OPERATED FOR BUSINESS OR PLEASURE? DESCRIBE PARTS DAMAGED AND EXTENT OF DAMAGE (NOTE: BY TERMS OF YOUR POLICY THE COMPANY MUST BE GIVEN REASONABLE OPPORTUNITY TO EXAMINE AUTO BEFORE REPAIRS ARE MADE) (IF GLASS DAMAGE, SEE REVERSE SIDE) WHERE MAY AUTO BE SEEN? YEAR BODY TYPE VEHICLE IDENTIFICATION NUMBER IF TRAILER, SERIAL NUMBER ADDRESS: STREET CITY STATE ZIP CODE ADDRESS: STREET CITY STATE ZIP CODE DRIVER'S LICENSE NUMBER WAS LICENSE IN EFFECT AT THE TIME OF ACCIDENT? BUSINESS PLEASURE WHO GAVE PERMISSION? WAS THE AUTO BEING USED FOR ERRAND FOR OWNER? ESTIMATED COST OF REPAIRS WHERE IS THE VEHICLE NORMALLY GARAGED? (CITY & STATE) OTHER AUTO INVOLVED PASSEN- GERS INJURIES (No Matter How Minor) MAKE OF AUTO YEAR LICENSE NUMBER ESTIMATED COST OF REPAIRS PARTS DAMAGED AND EXTENT OF DAMAGE NAME OF OWNER NAME OF DRIVER ADDRESS: STREET CITY STATE ZIP CODE ADDRESS: STREET CITY STATE ZIP CODE PHONE NUMBER PHONE NUMBER IS AUTO INSURED? YES NO NAME OF INSURANCE COMPANY NAMES OF PASSENGERS IN YOUR AUTO NAMES OF PASSENGERS IN OTHER AUTO ADDRESSES: STREET CITY STATE ZIP CODE ADDRESSES: STREET CITY STATE ZIP CODE NAMES OF PERSONS INJURED ADDRESSES INJURIES AGE IN WHICH AUTO WERE INJURED RIDING NAME OF DOCTOR OR HOSPITAL ADDRESS: STREET CITY STATE ZIP CODE PROPERTY DAMAGE OTHER THAN AUTO NAME OF OWNER ADDRESS: STREET CITY STATE ZIP CODE *GLASS BREAKAGE KIND OF PROPERTY ESTIMATED COST OF REPAIR WHERE MAY PROPERTY BE SEEN? *WITNESSES ADDRESSES: STREET CITY STATE ZIP CODE PHONE NUMBERS NAMES DESCRIP- TION OF ACCIDENT NOTE: By terms of your policy, the company must be given reasonable opportunity to examine auto before repairs are made. MY AUTO OTHER AUTO THIRD AUTO 1 2 3 PEDESTRIAN SHOW ON THE DIAGRAM THE POSITION OF ALL AUTOS, PERSONS, STOP LIGHTS, STOP SIGNS AND OTHER OBJECTS, SHOW STREET NAMES STOP SIGN YIELD SIGN STOP LIGHT LOCATION OF BREAKAGE TYPE OF GLASS WINDSHIELD DAMAGE: CHECK ITEMS ABOVE AND MARK LOCATION ON DIAGRAM: ON WHAT STREET OR ROAD WERE YOU DRIVING? STREET OR ROAD OTHER AUTO WAS DRIVING ON? DIRECTION SPEED DIRECTION SPEED YES NO BRIGHT DIM WERE YOUR LIGHTS ON? YES NO BRIGHT DIM WERE THE OTHER AUTO'S LIGHTS ON? WHAT TRAFFICONTROLS? FOR WHOM? SPEED LIMIT DID EITHER DRIVER GIVE SIGNAL OF ANY KIND? IF INTERSECTION, WHO ENTERED FIRST? WHO HAD RIGHT OF WAY? YES NO IF YES, WHO? WHICH DRIVER VIOLATED TRAFFIC ORDINANCE? CHARGE: DID POLICE INVESTIGATE ACCIDENT? YES NO POLICE ADDRESS? DESCRIBE, IN YOUR OWN WORDS, HOW ACCIDENT HAPPENED: DOOR VEN T REAR WINDSHIEL D OTHER, DESCRIBE TINTED SAFETY CLEAR PLATE TYPE OF BREAK CRACKED CHIPPED OR PITTED BULL'S EYE ( ) SHATTERED HALF MOON ( )) DO YOU THINK A CLAIM WILL BE MADE AGAINST YOU? BY WHOM? SIGNATURE DATE OF REPORT YES NO UNCERTAIN