Automobile Loss Claim Form
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Agent and Policy Information Section
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Insured Information - Section
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Contact Information (if different from named insured)
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Accident Information Section
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Description of Accident:* |
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Insured Vehicle Section
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Other Property Damage Section (Insured vehicle not included)
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Injury Section
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Injured Party 1 |
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Injured Party 2 |
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Witness Section
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Witness 1 |
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Witness 2 |
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Reporting Information Section
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If not reported by our insured, complete the information below |
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