Lemark Insurance Agency, Inc
Auto Loss Notice
AUTOMOBILE LOSS NOTICE
Please use the form below to notify our agency about a claim towards your automobile policy. You will contacted shortly by one of our qualified representatives. This does not constitute a claim until confirmed by one of our agents.

Policy Holder Information
You must include your phone number and/or email address
so that one of our representatives may contact you.

Full Name of Insured:
Address:
Phone #: Work: Home:
Email Address:
Insurance Policy #:

Time and Location of Accident
Time & Date of Accident
Time a.m.
p.m.		 Date
Location of Accident:
(Number, Street, Intersection, city,etc.)
Description of the Accident:

Your Vehicle Information
What car were you driving? Yr. Make Model
License Plate #: State
Is this your car? Yes No
If No, were you using it with permission? Yes No Please explain below:
Was There Damage Done to your vehicle? Yes No
If Yes, please describe:
Where can the vehicle be seen:

OTHER Driver Information
Name:
Address:
Phone: Work Home
Automobile: Yr. Make Model
Driver's License#: State
License Plate #: State
Insurance Company:
Describe damage to other vehicle:
Where can car be seen?

Injuries, Witnesses, Etc.
If there were any Injuries, please describe:
Please list any Witnesses and/or Passengers: (Please include Name, Address and Phone #)

Police Notification
Were the Police Called? Yes No
What Authority?
Were You Ticketed? Yes No
If Yes, what for?

Report Information
Reported by:
Title (if any):
Date:


Additional Comments
Please give any additional comments you feel appropriate for this Loss Notice.