AUTOMOBILE LOSS NOTICE
Completed By
*
Dealership the Unit is in Inventory
*
Please Select
COC
FOC/NOC
JOC/HOC
STOOPS
LEO INDY
LEO LEBANON
TWISTED TORCH HD
P4
RECON/COLLISION COLUMBUS
OTHER
DATE (MM/DD/YYYY)
-
Month
-
Day
Year
Date
AGENCY
INSURED LOCATION CODE
DATE OF LOSS AND TIME
-
Month
-
Day
Year
Date
AM
Hour Minutes
AM
PM
AM/PM Option
PM
Hour Minutes
AM
PM
AM/PM Option
CARRIER
NAIC CODE
CONTACT NAME:
POLICY NUMBER
PHONE (A/C, No, Ext):
POLICY TYPE
FAX (A/C, No):
E-MAIL ADDRESS:
example@example.com
CODE:
SUBCODE:
AGENCY CUSTOMER ID:
INSURED
NAME OF INSURED (First, Middle, Last)
INSURED'S MAILING ADDRESS
DATE OF BIRTH
-
Month
-
Day
Year
Date
FEIN (if applicable)
MARITAL STATUS
PRIMARY PHONE #
SECONDARY PHONE #
PRIMARY E-MAIL ADDRESS:
example@example.com
SECONDARY E-MAIL ADDRESS:
example@example.com
CONTACT
CONTACT INSURED
NAME OF CONTACT (First, Middle, Last)
CONTACT'S MAILING ADDRESS
PRIMARY PHONE #
SECONDARY PHONE #
WHEN TO CONTACT
PRIMARY E-MAIL ADDRESS:
example@example.com
SECONDARY E-MAIL ADDRESS:
example@example.com
LOSS
LOCATION OF LOSS
POLICE OR FIRE DEPARTMENT CONTACTED
STREET:
CITY, STATE, ZIP:
REPORT NUMBER
COUNTRY:
DESCRIPTION OF ACCIDENT (Attach additional sheets if more space is required)
INSURED VEHICLE
VEH #
YEAR
MAKE:
BODY TYPE:
PLATE NUMBER
STATE
MODEL:
V.I.N.:
OWNER'S NAME AND ADDRESS
(Check if same as insured)
PRIMARY PHONE #
SECONDARY PHONE #
PRIMARY E-MAIL ADDRESS:
example@example.com
SECONDARY E-MAIL ADDRESS:
example@example.com
DRIVER'S NAME AND ADDRESS
(Check if same as owner)
PRIMARY PHONE #
SECONDARY PHONE #
PRIMARY E-MAIL ADDRESS:
example@example.com
SECONDARY E-MAIL ADDRESS:
example@example.com
RELATION TO INSURED (Employee, family, etc.)
DATE OF BIRTH
-
Month
-
Day
Year
Date
DRIVER'S LICENSE NUMBER
STATE
PURPOSE OF USE
USED WITH PERMISSION? (Y/N)
DESCRIBE DAMAGE
ESTIMATE AMOUNT
WHERE CAN VEHICLE BE SEEN?
WHEN CAN VEHICLE BE SEEN?
OTHER INSURANCE ON VEHICLE - CARRIER:
POLICY NUMBER:
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OTHER VEHICLE / PROPERTY DAMAGED
NON VEHICLE?
AGENCY CUSTOMER ID:
VEH #
YEAR
MAKE:
BODY TYPE:
PLATE NUMBER
STATE
MODEL:
V.I.N.:
DESCRIBE PROPERTY (Other Than Vehicle)
OTHER VEH/PROP INS? (Y/N)
CARRIER OR AGENCY NAME
NAIC CODE
POLICY NUMBER
OWNER'S NAME AND ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PRIMARY PHONE #
SECONDARY PHONE #
PRIMARY E-MAIL ADDRESS:
example@example.com
SECONDARY E-MAIL ADDRESS:
example@example.com
DRIVER'S NAME AND ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
(Check if same as owner)
PRIMARY PHONE #
SECONDARY PHONE #
PRIMARY E-MAIL ADDRESS:
example@example.com
SECONDARY E-MAIL ADDRESS:
example@example.com
DESCRIBE DAMAGE
ESTIMATE AMOUNT
WHERE CAN DAMAGE BE SEEN?
INJURED
INJURED
Rows
NAME & ADDRESS
PHONE (A/C, No)
PED
INS VEH
OTH VEH
AGE
EXTENT OF INJURY
1
2
3
4
PED
INS OTH
WITNESSES OR PASSENGERS
WITNESSES OR PASSENGERS
Rows
NAME & ADDRESS
PHONE (A/C, No)
INS VEH
OTH VEH
OTHER (Specify)
1
2
3
VEH
REPORTED BY
REPORTED TO
REMARKS (Attach ACORD 101, Additional Remarks Section, if more space is required)
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AGENCY CUSTOMER ID:
APPLICABLE IN ALASKA
A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or
misleading information may be prosecuted under state law.
APPLICABLE IN ARIZONA
For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or
fraudulent claim for payment of a loss is subject to criminal and civil penalties.
APPLICABLE IN ARKANSAS, DELAWARE, DISTRICT OF COLUMBIA, KENTUCKY, LOUISIANA, MAINE,MICHIGAN, NEW JERSEY, NEW MEXICO, NORTH DAKOTA, PENNSYLVANIA, SOUTH DAKOTA,TENNESSEE, TEXAS, VIRGINIA, AND WEST VIRGINIA
Any person who knowingly and with intent to defraud any insurance company or another person, files a statement of claim containing
any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a
fraudulent insurance act, which is a crime, subject to criminal prosecution and civil penalties. In DC, LA, ME, TN, and VA, insurance
benefits may also be denied.
APPLICABLE IN CALIFORNIA
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or
fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
APPLICABLE IN COLORADO
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages.
Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information
to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.
APPLICABLE IN FLORIDA
Pursuant to S. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive any insurer or insured, prepares,
presents, or causes to be presented a proof of loss or estimate of cost or repair of damaged property in support of a claim under an
insurance policy knowing that the proof of loss or estimate of claim or repairs contains any false, incomplete, or misleading information
concerning any fact or thing material to the claim commits a felony of the third degree, punishable as provided in
S. 775.082, S. 775.083, or S. 775.084, Florida Statutes.
APPLICABLE IN HAWAII
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime
punishable by fines or imprisonment, or both.
APPLICABLE IN IDAHO
Any person who knowingly and with the intent to injure, defraud, or deceive any insurance company files a statement of claim containing
any false, incomplete or misleading information is guilty of a felony.
APPLICABLE IN INDIANA
A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading
information commits a felony.
APPLICABLE IN MARYLAND
Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
APPLICABLE IN MINNESOTA
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
APPLICABLE IN NEVADA
Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or
misleading information concerning a material fact is guilty of a felony.
ACORD 2 (2009/01)
Page 3 of 4
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AGENCY CUSTOMER ID:
APPLICABLE IN NEW HAMPSHIRE
Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
APPLICABLE IN NEW YORK
Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who in connection with such application or claim knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the Department of Motor Vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
APPLICABLE IN OHIO
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
APPLICABLE IN OKLAHOMA
WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
APPLICABLE IN WASHINGTON
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
ACORD 2 (2009/01)
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