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?:
Were You Ticketed or at fault? Yes  No
If Yes, explain?

Vehicle Involved
Did you damage your vehicle? Yes     No
If Yes, explain:
Where is car located:
Which insured car  were you driving?
Yr.
Make:
Model:
License Plate #:
State:
Vin #:
Do we insure this car? Yes     No
If No, were you using it with permission? Yes     No
Please explain:
   

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

Address:
Phone: Work     
  Home
Automobile: Yr.    
  Make  
  Model
Driver's License #:    State
License Plate #:    State
Their Insurance Company:
Their Policy Number:
Describe damage to the other car:
Where is the car now?
   

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)