Account/Loss Information
- Caller's phone number and extension
- Caller's title and name
- Garage state (state where vehicle is garaged)
- Subsidiary name and address
- Subsidiary mailing address (if different from above)
- Did the loss occur at the location address? (if no, address where loss occurred)
- Date and time of loss
- Full description of loss
- Parent company/insured's name
- Location code
- Policy symbol and number
Insured Vehicle and Injury Information
- Does insured own vehicle? (if no, owner's name, address and phone number)
- Insured vehicle year, make, model, vehicle identification number, plate state and number
- Insured vehicle driver name, address, phone number, relationship to the insured, date of birth, driver license state and number
- Insured vehicle used with permission?
- Was the insured vehicle damaged? If yes, description of damage.
- Is there a written estimate or repair/replacement bill for the damage? If yes, amount.
- Is vehicle drivable?
- Did air bag deploy?
- Attorney information (if represented)
- Was anyone injured in the insured vehicle? If yes, provide the following information for each injured person in insured's vehicle:
- name
- business and home phone numbers
- address
- relationship of the injured to the accident (insured driver, member of insured household, guest in insured vehicle, or pedestrian)
- date of birth
- gender
- description of injury
- medical facility (if treatment received)
- attorney information (if represented)
Other Property Damage and Injury Information
- Was any other vehicle damaged? If yes, provide the following information:
- owner's name
- business and home phone numbers
- address
- damaged vehicle information (year, make, model, vehicle identification number, color, plate state and number )
- description of damage
- Is there a written estimate or repair/replacement bill for the damage? If yes, amount.
- Did air bag deploy?
- Other insurance carrier information (name and policy number)
- Attorney information (if represented)
- Was any other property damaged? If yes, provide the following information:
- name
- business and/or home phone numbers
- address
- description of damaged property
- location of damaged property including address
- Is a written estimate or repair/replacement bill for damage available? If yes, amount.
- attorney information (if represented)
- Was anyone injured in any of the other vehicles involved? If yes, provide the following information:
- name
- business and home phone numbers
- address
- relationship of the injured to the accident (driver or occupant of other vehicle, pedestrian)
- date of birth
- gender
- description of injury
- medical facility (if treatment received)
- attorney information (if represented)
- Witnesses (names, addresses, and phone numbers)
- Authorities (name, report/case number, county, any violations/citations)
Contact Information
- Contact name and phone number, best time to contact and where to contact
- Additional notes/comments or customer specific information
