| Automobile Loss Notice |
| Please use the form below to notify
us of any loss or damage to your automobile(s)
insured through this Rutherford One Insurance
Services. Please note that this form is
for notification purposes only and does
not constitute making an actual claim. One
of our representatives will contact you
shortly after receiving this notification. |
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Disclaimer:
I understand that this does not constitute an actual claim, but is rather a notification to my agent of an existing loss or claim, and may help expedite the claim process once I have filed.
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I have read and agree with the above
(Box must be checked before request can be sent) |
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| Policy Holder Information |
| Please be sure to supply your phone number and email address so that we may contact you after receiving this notification. |
| Name Insured: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Work Phone: |
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| Home Phone: |
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| Email: |
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| Time and Location of Accident |
| Time: |
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A.M.
P.M. |
| Date: |
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Location of Accident:
(Number, Street, Intersection, etc.) |
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| Description of Accident: |
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| Police Notification |
| Were the Police Called? |
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Yes
No |
| What Authority? |
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| Were you Ticketed? |
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Yes
No |
| If Yes, what for? |
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| Vehicle Information |
| Damage to Your Vehicle? |
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Yes
No |
| If Yes, describe: |
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| Where Can Vehicle Be Seen? |
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| Vehicle Year: |
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| Make: |
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| Model: |
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| License Plate Number: |
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| State: |
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| Is This Your Car? |
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Yes
No |
| If No, were you using it with permission? |
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Yes
No |
| Please Explain: |
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| Other Driver Information |
| Name: |
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| Address: |
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| Work Phone: |
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| Home Phone: |
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| Vehicle Year: |
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| Make: |
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| Model: |
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| Driver's License Number: |
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| Driver's License State: |
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| License Plate Number: |
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| Licens Plate State: |
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| Insurance Company: |
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| Describe Damage to Other Vehicle: |
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| Where Can Vehicle Be Seen? |
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| If There Were Any Injuries, Please Describe: |
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Please List Any Witnesses and/or Passengers:
(Please include name, address, and phone) |
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| Report Information |
| Reported By: |
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| Title (if any): |
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| Date: |
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| Additional Comments |
| Please give any additional comments you feel appropriate for this Loss Notice. |
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| Please click on the "Submit" button to send your Loss Notice. One of our representatives will respond to your submission as soon as possible. |
Enter the 6 letters you see above:
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