Miller & Associates Insurance Group

Policy Holder

Please be sure to complete all of the requested information so that your agent may contact you after receiving this notification.

Named Insured::

Street Address:

City, State, Zip

Name of Contact/
Person Filing Claim

Phone Numbers: Work

Home

E-mail Address:

Fax Number

Details of Claim/Loss

Time & Date of Loss

Time AM PM Date

Location:
(Number, Street, Intersection, etc.)

Detailed Description:
(use additional comments below if necessary)

Were the Police Notified?

Yes No

Department?:

Case Number?:

Other Party Information
If this claim involved another party, please provide us with as much information as possible

Name:

Address:

Phone:

Work

Home

Injuries, Witnesses, Etc.

If there were any Injuries, please describe:

Please list any Witnesses and/or Passengers:

(Please include Name, Address and Phone #)

Additional Information
In the box below, please provide any additional information you feel may be necessary for this Loss Notice form.

Submission of a loss notice does not represent, assure or guarantee that coverage will be provided by your insurance program. If information is required, you will be contacted by either a representative of Miller & Associates or your insurance company.

Any person who knowingly, and with the intent to injure, defraud, or deceive a company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony and / or subject to criminal prosecution, civil penalties; punishable by imprisonment or fines.

I have read and agree with the above disclaimer (It is mandatory to check box before request can be sent)