FIRST NOTICE OF LOSS
AUTO
GB Account #: 010912
VDN: 2225720
DATE AND TIME OF INCIDENT
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Day
Year
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Hour
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Minutes
AM
PM
AM/PM Option
Authority Name
*
Reporting Party Name
*
First Name
Last Name
Reporting Party
example@example.com
Reporting party phone #
*
-
Area Code
Phone Number
Member Vehicle Information
LICENSE PLATE #
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle VIN
Authority Driver Name
First Name
Last Name
Authorized Driver?
Yes
No
Were any injuries reported?
*
Yes
No
Describe What Occurred
Other Vehicle Information
Was Another Vehicle Involved?
Yes
No
Multiple Vehicles
Other
Vehicle Driver / Owner Name
First Name
Last Name
Other Driver Phone Number
-
Area Code
Phone Number
VEHICLE OWNER ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
VEHICLE OWNER DATE OF BIRTH
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Month
-
Day
Year
Date
LICENSE PLATE #
License State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle VIN
Insurance Company
Policy #
Claim #
Insurance Company Phone #
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Area Code
Phone Number
Accident Details
DESCRIBE WHAT HAPPENED
Please be as detailed as possible
Accident Location
Street Address
Intersecting With
City/Town/Village
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Was any building or other property damaged?
Police Report?
Yes
No
POLICE REPORT #
POLICE DEPT.
TYPE OF ACCIDENT
*
Please Select
REAR ENDED vehicle ahead
Hit from behind
PASSING
RIGHT TURN
LEFT TURN
HEAD ON
RIGHT ANGLE
SIDE SWIPE
FIXED OBJECT
OTHER
IV R/E OV
OV R/E IV
OV2 R/E IV INTO OV
UNK HIT AND RUN
Burn
TRAFFIC CONDITIONS
*
Please Select
LIGHT
MODERATE
HEAVY
TRAFFIC CONTROL
*
Please Select
NONE
YIELD SIGN
DRIVER RED FLASH
DRIVER YELLOW FLASH
LEFT TURN SIGNAL
STOP SIGN
FOUR WAY STOP
THREE LIGHT SIGNAL/DEDICATED LEFT TURN
WORK ZONE
OTHER
LIGHT CONDITIONS
*
Please Select
DAYLIGHT
DARKNESS
DUSK/DAWN
TRAFFIC/WEATHER
*
Please Select
CLEAR
CLOUDY
RAIN
SNOW
HAIL/SLEET
FOG/SMOKE
ROADWAY CHARACTER
*
Please Select
STRAIGHT/LEVEL
STRAIGHT/GRADE
STRAIGHT/HILLCREST
CURVE/LEVEL
CURVE/GRADE
CURVE/HILL CREST
ADJACENT PARKED VEHICLE LANES
ROAD SURFACE
*
Please Select
DRY
WET
ICY
SNOW/SLUSH
MUDDY
OTHER
ROADWAY MARKINGS
Please Select
Double Yellow lines
My side yellow line
Other vehicle yellow line
none
POST IMPACT/VEHICLE POSITION
Please Select
My vehicle cross yellow
other vehicle cross yellow
yellow line
other
SPEED LIMIT
*
Please Select
15 MPH
25 MPH
30 MPH
35 MPH
40 MPH
45 MPH
50 MPH
55 MPH
60 MPH
65 MPH
70 MPH
75 MPH
80 MPH
Evasive Action Taken
*
Braked
swerved to left
served to right
vehicle stopped at light
vehicle parked
Sped up
slowed down
honked horn
Road Rage
Other
Additional Information: Witness and Other Vehicles
Witnesses?
Yes
No
Full Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
ALT. Phone Number
-
Area Code
Phone Number
VEHICLE #
Please Select
1
2
3
LICENSE PLATE #
License State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
VEHICLE MAKE
VEHICLE MODEL
Point of Impact
Please Select
Front
Rear
left side
right side
left front quarter panel
right front quarter panel
left rear quarter panel
right rear quarter panel
Color
VEH. IDENTIFICATION #
Drive able?
Yes
No
PERMISSION TO MOVE?
Please Select
YES
NO
Vehicle Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Contact person
First Name
Last Name
Location Contact number #
-
Area Code
Phone Number
DESCRIBE VEHICLE DAMAGE
Additional Vehicle?
Yes
No
VEHICLE #
Please Select
1
2
3
DRIVER NAME
DRIVERS LIC #
*
DRIVER ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DRIVER PHONE #
-
Area Code
Phone Number
DOB
-
Month
-
Day
Year
Date
LICENSE PLATE #
*
LICENSE STATE
*
VEHICLE MAKE
*
VEHICLE MODEL
*
Point of Impact
Please Select
Front
Rear
left side
right side
left front quarter panel
right front quarter panel
left rear quarter panel
right rear quarter panel
Color
VEH. IDENTIFICATION #
*
Drive able?
Yes
No
INSURANCE COMPANY
Please Select
ALLSTATE
STATE FARM
GEICO
ESURANCE
SHELTER
GAINSCO
SAFEWAY
SAFECO
GEICO
AAA
ALLIANCE UNITED
ANCHOR GENERAL
CALIFORNIA CASUALT
WAWANESA
WESTERN GENERAL
FARMERS
NATIONWIDE
GOOD TO GO
NATIONAL GENERAL
SOUTHERN GENERAL
MERCURY
TOPA
HALLMARK
CALIFORNIA CASUALTY
AIG
LIBERTY MUTUAL
ASPIRE
GALLAGHER BASSETT
CANAL
AMERIPRSE
KEMPER
ANCHOR GENERAL
WESTERN NATIONAL
PRONTO
INSURANCE HOUSE
GERMANIA
POLICY #
Please Select
ALLSTATE
STATE FARM
GEICO
ESURANCE
SHELTER
GAINSCO
SAFEWAY
SAFECO
GEICO
AAA
ALLIANCE UNITED
ANCHOR GENERAL
CALIFORNIA CASUALT
WAWANESA
WESTERN GENERAL
FARMERS
NATIONWIDE
GOOD TO GO
NATIONAL GENERAL
SOUTHERN GENERAL
MERCURY
TOPA
HALLMARK
CALIFORNIA CASUALTY
AIG
LIBERTY MUTUAL
ASPIRE
GALLAGHER BASSETT
CANAL
AMERIPRSE
KEMPER
ANCHOR GENERAL
WESTERN NATIONAL
PRONTO
INSURANCE HOUSE
GERMANIA
CLAIM #
Please Select
ALLSTATE
STATE FARM
GEICO
ESURANCE
SHELTER
GAINSCO
SAFEWAY
SAFECO
GEICO
AAA
ALLIANCE UNITED
ANCHOR GENERAL
CALIFORNIA CASUALT
WAWANESA
WESTERN GENERAL
FARMERS
NATIONWIDE
GOOD TO GO
NATIONAL GENERAL
SOUTHERN GENERAL
MERCURY
TOPA
HALLMARK
CALIFORNIA CASUALTY
AIG
LIBERTY MUTUAL
ASPIRE
GALLAGHER BASSETT
CANAL
AMERIPRSE
KEMPER
ANCHOR GENERAL
WESTERN NATIONAL
PRONTO
INSURANCE HOUSE
GERMANIA
Vehicle Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Contact person
First Name
Last Name
Location Contact number #
-
Area Code
Phone Number
DESCRIBE VEHICLE DAMAGE
*
Additional Vehicle
Yes
No
VEHICLE #
Please Select
1
2
3
DRIVER NAME
DOB
-
Month
-
Day
Year
Date
DRIVERS LIC #
*
LICENSE PLATE #
*
LICENSE STATE
*
VEHICLE MAKE
*
VEHICLE MODEL
*
Point of Impact
Please Select
Front
Rear
left side
right side
left front quarter panel
right front quarter panel
left rear quarter panel
right rear quarter panel
Color
VEH. IDENTIFICATION #
*
Drive able?
Yes
No
Vehicle Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Contact person
First Name
Last Name
Location Contact number #
-
Area Code
Phone Number
DESCRIBE VEHICLE DAMAGE
*
INJURIES
Injuries?
Yes
No
Injured in VEHICLE #
Please Select
Driver Vehicle 1
Driver Vehicle 2
Driver Vehicle 3
Passenger Vehicle 1
Passenger Vehicle 2
Passenger Vehicle 3
Injured Party Name
Injured Party Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Injured party phone #
-
Area Code
Phone Number
Injured vehicle position
Please Select
Driver front
Passenger front
Passenger left rear
Passenger right rear
Seat belt in use?
Yes
No
Body Part Injured
Neck
back
face
right leg
left leg
right knee
left knee
right arm
left arm
right hand
left hand
right wrist
left wrist
Right fingers
left fingers
chest
stomach
fatality
scar
Other
BRIEFLY DESCRIBE INJURIES
Additional party injuries?
Yes
No
Injured in VEHICLE #
Please Select
Driver Vehicle 1
Driver Vehicle 2
Driver Vehicle 3
Passenger Vehicle 1
Passenger Vehicle 2
Passenger Vehicle 3
Injured Party Name
Injured Party Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Injured party phone #
-
Area Code
Phone Number
Injured vehicle position
Please Select
Driver front
Passenger front
Passenger left rear
Passenger right rear
Seat belt in use?
Yes
No
Body Part Injured
Neck
back
face
right leg
left leg
right knee
left knee
right arm
left arm
right hand
left hand
right wrist
left wrist
Right fingers
left fingers
chest
stomach
fatality
scar
Other
BRIEFLY DESCRIBE INJURIES
Additional party injuries?
Yes
No
Injured in VEHICLE #
Please Select
Driver Vehicle 1
Driver Vehicle 2
Driver Vehicle 3
Passenger Vehicle 1
Passenger Vehicle 2
Passenger Vehicle 3
Injured Party Name
Injured Party Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Injured party phone #
-
Area Code
Phone Number
Injured vehicle position
Please Select
Driver front
Passenger front
Passenger left rear
Passenger right rear
Seat belt in use?
Yes
No
Body Part Injured
Neck
back
face
right leg
left leg
right knee
left knee
right arm
left arm
right hand
left hand
right wrist
left wrist
Right fingers
left fingers
chest
stomach
fatality
scar
Other
BRIEFLY DESCRIBE INJURIES
Attorney Represented?
Yes
No
Firm Name
Attorney Name
First Name
Last Name
Attorney Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Attorney phone #
-
Area Code
Phone Number
Suit Filed?
Yes
No
Suit Filing Date
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Month
-
Day
Year
Date
Please add any other significant information
0/500
Today's Date
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SUBMIT
_________________________________________________________________________
Georgia Fraud Advisement
GEORGIA LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: Any natural person who knowingly and willfully with intent to defraud subscribes, makes, or concurs in making any annual or other statement required by law to be filed with the Commissioner containing any material statement which is false commits the crime of insurance fraud.
Vermont Fraud Advisement
VERMONT LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.
Acknowledgement of Claim
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