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