First Notice of Loss (FNOL)

REPORT A CLAIM

TRANSPORTATION
Insurance Carrier (Policy Paper)
Avant Program Name - Claim Type

Other
Client Reference Number (if applicable)
Internal claim number (example)
REPORTING PARTY INFORMATION

Your relationship to the claim
Loss/Accident Reported by:

Other
Reporter Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
POLICYHOLDER (INSURED) INFORMATION
Policyholder (Insured) Name
Policy Number
Policy Number can be found on the Declarations Page
Did the Loss/Accident happen to the Policyholder (Insured)?
*NOTE: If your Loss/Accident is outside the reporting period (policy inception-policy expiration date), please contact your Broker/Insurance Agent for additional assistance.
LOSS INFORMATION
Date of Loss/Accident

MonthDayYear
Date
Location of Loss / Accident

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code (5 digits)
Description of Loss / Accident
Describe in detail what happened. How did it happen? Why did it happen? Who was involved? Please include as much detailed information, as possible.
Please describe any Injuries resulting from the Loss/Accident
Describe in detail injuries sustained, body part(s). Hospital & Physician Name(s) - contact information.
INSURED INFORMATION (1st Party) - WHO WAS INVOLVED?

Person(s) involved in the Loss / Accident (Named Insured on Policy)
Full Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insured (1st Party) Vehicle Information - if applicable
Was there a vehicle involved in the Loss/Accident?
What type of vehicle was involved?
Vehicle Vin #
Vehicle Year
Example: 2025
Vehicle Make
Example: Freightliner
Vehicle Model
Example: Cascadia 125
Truck Number
If applicable, motor carrier tracking number
Additional Vehicle(s) Involved with Accident/Loss. Please include VIN#, Year, Make, Model
Please include ALL vehicles associated with the Loss/Accident .
Are Vehicle(s) drivable?
Were Vehicle(s) towed from the Loss/Accident location?
Towing Company Name, if applicable
Towing Company Contact Information, if applicable

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code (5 digits)
Towing Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Other Party Information (3rd Party) - if applicable

Person(s) involved in the Loss/Accident - NOT the Policyholder/Insured
Full Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth - Other Party

MonthDayYear
Date
Social Security Number - Other Party (last 5-digits only)
Example: 22222
Additional information regarding "Other Party"
Additional parties involved in the Loss/Accident, Contact & Vehicle Information, Comments/Details
INVESTIGATION / DISCOVERY
Police Report
Police Department Name, if applicable
Police Report Number, if applicable
Attach Supporting Documents

Please insert Police Report, Photos/Videos, Accident Reports, other documents related to the Accident/Loss.
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Were there any Witnesses to the Loss/Accident?
Witness Contact Information

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Comments/Discovery for consideration.
This could be additional details/comments, other Party to the Loss (please include name/phone number)
CLAIMS CONTACT INFORMATION
Avant Specialty Claims

Email: claims@avantclaims.com

Claims Support: 800-542-2441

New Loss Reporting: 877-245-3823

Mailing Address:

Avant Specialty Claims
A Division of Specialty Program Group (SPG)
PO Box 5188
El Dorado Hills, CA 95762
Is this an escalated claim? *** Immediate Attention ***
Additional Details for Escalated Claim - Immediate Attention Request:
Purpose for escalation, additional details/facts/concerns
Fraud Warning:

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinment in prison.
Submission Date
Should be Empty:

REPORT A CLAIM

REPORTING PARTY INFORMATION

POLICYHOLDER (INSURED) INFORMATION

LOSS INFORMATION

INSURED INFORMATION (1st Party) - WHO WAS INVOLVED?

Insured (1st Party) Vehicle Information - if applicable

Other Party Information (3rd Party) - if applicable

INVESTIGATION / DISCOVERY

CLAIMS CONTACT INFORMATION

Avant Specialty Claims