INSURED INFORMATION

Auto Liability First Notice of Loss Report
CARRIER/CLAIMS ADMINISTRATOR
National Interstate Insurance Company,

Phone: (800) 929-0870 Fax: (330) 659-8900 Email: newclaims@natl.com

Online: www.natl.com
INSURED INFORMATION
Insured (Name, Address)
Name of Person Preparing This Form
Date Form Prepared

MonthDayYear
Date
Insured Contact Name (if different than preparer)
External Claim Number
Insured Phone
Insured FEIN
Insured Contact E-mail Address
example@example.com
Phone Number
Policy Number
Insured Location Name and Address (if different)
Report Only

Yes No
Policy Date From

MonthDayYear
Date
Policy Date to

MonthDayYear
Date
FACTS OF LOSS
Date of Loss

MonthDayYear
Date
Did accident occur on employees premisses

Yes No
Which time frame did it occur

AM PMWho is your workers compensation carrier?
Location of Loss (Be as specific as possible including up to business name, highway, mile marker, address, city and state)
Time Of Accident

Hour Minutes
Accident Description
Accident State
OUR INDIVIDUALS INVOLVED
Driver’s Name (First, Middle, Last)
Driver’s License State
Gender

MaleFemale
Injured, if so (body parts and nature of injury)
Driver’s Address
Driver’s Address
Driver’s Address
Driver’s License Number
Medical Treatment Code
If yes, list provider name and address below:

Was treatment sought? Yes NoMedical Treatment Code
If yes, list provider name and address below:
If yes, list provider name and address below
Email Address
example@example.com
Insured Driver Phone Number
Date of Birth

MonthDayYear
Date
Social Security Number
Initial Service Date

Yes NoWas surgery needed?
Passengers: Name (First, Last)
Relationship
Gender

MaleFemale
If yes, list injuries (body parts and nature of injury)
Address
Address
Address
Address
Driver’s License Number
If yes, list provider name and address below:

Was treatment sought? Yes NoMedical Treatment Code
If yes, list provider name and address below:
If yes, list provider name and address below
If yes, list provider name and address below
Phone Number
example@example.com
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Auto Liability First Notice of Loss Report

YesNo If yes, enter all information on the Witness Sheet.Were there any witnesses to the accident?
VEHICLE INFORMATION
Year
Make
Model
VIN Number
License Plate Number
License Plate State
Current Mileage
Area Damaged
Non vehicle damage?

Yes NoWas vehicle pulling a trailer?
Non vehicle damage?

Yes NoIs vehicle drivable?
Vehicle Class Type
Color
Point of Impact
Number of Passengers
Name Associated with Vehicle
Type/Model of AER

Event Recorder? Yes NoModel
OTHER VEHICLE INFORMATION
Year
License Plate State
License Plate State
Current Mileage
Estimated Speed at Time of Loss
Area Damaged
Non vehicle damage?

Yes NoWas vehicle pulling a trailer?
Color
VIN
Point of Impact
Number of Passengers
Name Associated with Vehicle
Type/Model of AER

Event Recorder? Yes No*** For any additional vehicles involved, please use the template sheet for Other Vehicles Involved.
MOTOR VEHICLE ACCIDENT INFORMATION
Accident Road Type
Road Conditions
Weather Conditions
On entrance or exit ramp?

Yes NoTrip Origin Address
Address

Trip Destination Address

Street Address Line 2

CityState / Province

Zip
City
State
Zip
Auto Liability First Notice of Loss Report
POLICE REPORT INFORMATION
Police report made?

Yes NoWas Someone Cited?
Police Department Name
Police Department Precinct
Yes No
Officer’s Badge Number
Police Report Number
Agency Type
Association of Cited
List Citations
Name Of Person Cited
ADDITIONAL INFORMATION
Is there anything else we should know?
INDIVIDUALS/INJURIES INVOLVED
Name (First, Last)
Name (First, Last)
Relationship
Driver’s License State
Gender

MaleFemale
If yes, list injuries (body parts and nature of injury):

NoWas driver injured? Yes
If yes, list injuries (body parts and nature of injury)
Address
Address
Address
Address
Driver’s License Number
Medical Treatment Code
If yes, list provider name and address below:

Was treatment sought? Yes NoMedical Treatment Code
If yes, list provider name and address below:
If yes, list provider name and address below
If yes, list provider name and address below
If yes, list provider name and address below
Phone Number Individual Involved
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Phone Number
Initial Service Date

MonthDayYear
Date
Initial Service Date

Yes NoWas driver injured? Yes
INDIVIDUALS/INJURIES INVOLVED
Name (First, Last)
Name (First, Last)
Relationship
Driver’s License State
Gender

Male&emĂůehnŬnoǁn
Gender

NoIf yes, list injuries (body parts and nature of injury):
If yes, list injuries (body parts and nature of injury)
Address
Address
Address
Address
Driver’s License Number
Medical Treatment Code
If yes, list provider name and address below:

Was treatment sought? Yes NoMedical Treatment Code
If yes, list provider name and address below:
If yes, list provider name and address below
If yes, list provider name and address below
If yes, list provider name and address below
If yes, list provider name and address below:

Yes NoIf treatment, was employee admitted?
Phone Number Individual Involved
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Social Security Number
WƌŽǀideƌPhone
Initial Service Date

MonthDayYear
Date
Initial Service Date

Yes NoWas surgery needed?
INDIVIDUALS/INJURIES INVOLVED
Name (First, Last)
Name (First, Last)
Relationship
Driver’s License State
Gender

Male&emĂůehnŬnoǁn
If yes, list injuries (body parts and nature of injury):

NoWas driver injured? Yes
If yes, list injuries (body parts and nature of injury)
If yes, list injuries (body parts and nature of injury):

Yes NoIf treatment, was employee admitted?
Address
Address
Address
Address
Driver’s License Number
Medical Treatment Code
If yes, list provider name and address below:

Was treatment sought? Yes NoMedical Treatment Code
If yes, list provider name and address below:
If yes, list provider name and address below
If yes, list provider name and address below
If yes, list provider name and address below
Phone Number Individual Involved
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Social Security Number
WƌŽǀideƌPhone
Initial Service Date

MonthDayYear
Date
Initial Service Date

Yes NoWas surgery needed?
INDIVIDUALS/INJURIES INVOLVED
Name (First, Last)
Name (First, Last)
Relationship
Driver’s License State
Gender

Male&emĂůehnŬnoǁn
If yes, list injuries (body parts and nature of injury):

Was driver injured? YesNo
If yes, list injuries (body parts and nature of injury)
If yes, list injuries (body parts and nature of injury):

Yes NoIf treatment, was employee admitted?Was surgery needed?
Address
Address
Address
Address
Driver’s License Number
Medical Treatment Code
If yes, list provider name and address below:

Was treatment sought? Yes NoMedical Treatment Code
If yes, list provider name and address below:
If yes, list provider name and address below
If yes, list provider name and address below
If yes, list provider name and address below
Phone Number Individual Involved
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Social Security Number
WƌŽǀideƌPhone
Initial Service Date

MonthDayYear
Date
Initial Service Date

Yes NoAdditional Individuals Information
VEHICLE INFORMATION
Year
Make
Model
VIN Number
License Plate Number
License Plate State
Current Mileage
Estimated Speed at Time of Loss
Area Damaged
Non vehicle damage?

Yes NoWas vehicle pulling a trailer?
Non vehicle damage?

Yes NoIs vehicle drivable?
Damage Estimate
Vehicle Class Type
Color
Trailer VIN
Type of Trailer
Type of Trailer

Yes NoWas there a cargo spill?
Point of Impact
Was vehicle towed?

Yes NoWas vehicle parked?
Was vehicle towed?

Yes NoIs vehicle a total loss?
Number of Passengers

Yes NoIf stolen, was vehicle recovered?
Number of Passengers
Yes No

MakeLicense Plate State
Yes No

Yes NoIs there a fuel or other spill?
Yes No

Event Recorder? Yes NoDoes vehicle have an Automated
Yes No

No YesType/Model of AER
Name Associated with Vehicle
Name Associated with Vehicle
Yes No
VEHICLE INFORMATION
Year
Model
Model
VIN Number
License Plate Number
Current Mileage
Current Mileage
Estimated Speed at Time of Loss
Area Damaged
Non vehicle damage?

Yes NoWas vehicle pulling a trailer?
Non vehicle damage?

Yes NoIf stolen, was vehicle recovered?
E Damagestimate
Vehicle Class Type
Color
Trailer VIN
Trailer VIN

Yes NoWas vehicle towed?
Type of Trailer
Type of Trailer

Yes NoIs vehicle a total loss?
Point of Impact

Yes NoIs vehicle drivable?
Point of Impact
Number of Passengers
Number of Passengers
Number of Passengers
Was vehicle parked?

Yes NoNo Yes
Was vehicle parked?

Is there a fuel or other spill?Was there a cargo spill?
Was vehicle parked?
Was vehicle parked?

Yes NoAdditional Vehicle Information
Yes No

Name Associated with VehicleType/Model of AER
Yes No

Event Recorder? Yes NoDoes vehicle have an Automated
WITNESS #1 INFORMATION
Witness’ Name (First, Last)
Witness’ Name (First, Last)
Witness’ Name (First, Last)

Check Box if Unknown:
Witness’ Address
Witness’ Address
Witness’ Address
Witness’ Address
Witness' Phone Number
Gender

MaleFemaleUnknown
Email
example@example.com
Date of Accident

MonthDayYear
Date
Was anyone hurt?

Witness Report and StatementsYes No
Was anyone hurt?

GenderIf motor vehicle accident, were you a
Was anyone hurt?

Yes No N/Apassenger in any of the vehicles involved?If motor vehicle accident, were you a
Yes No

Were you an eye witness to the actual accident?Describe the accident and what you saw:
Yes No
If yes, who?

Yes No UnknownYes NoIf no, did you come to the scene shortly after?
If yes, who?
WITNESS #2 INFORMATION
Witness’ Name (First, Last)
Witness’ Name (First, Last)
Witness’ Name (First, Last)

Check Box if Unknown:
Witness’ Address
Witness’ Address
Witness’ Address
Witness’ Address
Witness' Phone Number
Gender

MaleFemaleUnknown
Email
example@example.com
Date of Accident

MonthDayYear
Date
Did you see the

Yes Noaccident?
Was anyone hurt?

Yes NoIf yes, who?
Was anyone hurt?

GenderWitness' Phone Number
Was anyone hurt?

Yes No N/Apassenger in any of the vehicles involved?Email
If yes, who?

Yes No UnknownIf no, did you come to the scene shortly after? Yes NoWere you an eye witness to the actual accident?
If yes, who?
Describe the accident and what you saw
Describe the accident and what you saw:
Should be Empty:

Auto Liability First Notice of Loss Report

CARRIER/CLAIMS ADMINISTRATOR

INSURED INFORMATION

FACTS OF LOSS

OUR INDIVIDUALS INVOLVED

VEHICLE INFORMATION

OTHER VEHICLE INFORMATION

MOTOR VEHICLE ACCIDENT INFORMATION

Auto Liability First Notice of Loss Report

POLICE REPORT INFORMATION

ADDITIONAL INFORMATION

INDIVIDUALS/INJURIES INVOLVED

INDIVIDUALS/INJURIES INVOLVED

INDIVIDUALS/INJURIES INVOLVED

INDIVIDUALS/INJURIES INVOLVED

VEHICLE INFORMATION

VEHICLE INFORMATION

WITNESS #1 INFORMATION

WITNESS #2 INFORMATION