Automobile Loss Notice Form

Last Report Generated (click to view or download)
 Employer Name
 Location Name
 Department Name
 FROL ID
 Hidden Record ?
 Record Marked for Delete ?

        Basic Case Information
 Report Number
 Date Prepared
 Date Of Loss
 Time Of Loss
 For Information Only
 Claim Status
 Carrier Claim Number
 First Incident Identifier
 Second Incident Identifier

        Agency Information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Contact
 Contact Phone
 Fax
 Contact Email
 Agency Code
 Agency Subcode
 Customer ID
 Insured Location Code
 Carrier Name
 Carrier NAICS
 Policy Number
 Policy Type

        Insured Information
 Name
 Date of Birth
 FEIN
 Marital Status
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 Address 1
 Address 2
 City
 State
 Zip
 Primary Email
 Secondary Email

        Contact Information
 Contact Insured
 Name
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 When To Contact
 Address 1
 Address 2
 City
 State
 Zip
 Primary Email
 Secondary Email

        Loss Information
 Address
 City
 State
 Zip
 Country
 Police or Fire Department Contacted
 Police or Fire Department Report Number
Description of Accident (150 characters max)

        Insured Vehicle Information
 Vehicle Number
 Year
 Make
 Model
 Body Type
 VIN
 Plate Number
 State
 Owner Is Insured
 Owner Name
 Owner Address 1
 Owner Address 2
 Owner City
 Owner State
 Owner Zip
 Owner Primary Phone
 Owner Primary Phone Type
 Owner Secondary Phone
 Owner Secondary Phone Type
 Owner Primary Email
 Owner Secondary Email
 Driver Is Owner
 Driver First Name
 Driver Initial
 Driver Last Name
 Driver Address 1
 Driver Address 2
 Driver City
 Driver State
 Driver Zip
 Driver Primary Phone
 Driver Primary Phone Type
 Driver Secondary Phone
 Driver Secondary Phone Type
 Driver Primary Email
 Driver Secondary Email
 Driver Relation To Insured
 Driver Date Of Birth
 Driver License Number
 Driver License State
 Purpose Of Use
 Used With Permission
Describe Damage (300 characters max)
 Estimate Amount
 Can Be Seen Where
 Can Be Seen When
 Other Carrier
 Other Policy Number

        Other Vehicle / Property Damaged Information
 Non Vehicle Damage
 Vehicle Number
 Year
 Make
 Model
 Body Type
 VIN
 Plate Number
 State
Describe Property (100 characters max)
 Is Property Insured
 Carrier Name
 Carrier NAICS
 Policy Number
 Owner Name
 Owner Address 1
 Owner Address 2
 Owner City
 Owner State
 Owner Zip
 Owner Primary Phone
 Owner Primary Phone Type
 Owner Secondary Phone
 Owner Secondary Phone Type
 Owner Primary Email
 Owner Secondary Email
 Driver Is Owner
 Driver First Name
 Driver Initial
 Driver Last Name
 Driver Address 1
 Driver Address 2
 Driver City
 Driver State
 Driver Zip
 Driver Primary Phone
 Driver Primary Phone Type
 Driver Secondary Phone
 Driver Secondary Phone Type
 Driver Primary Email
 Driver Secondary Email
Describe Damage (300 characters max)
 Estimate Amount
 Can Be Seen Where

        Injured Information
First Injury information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Phone
 Is Pedestrian
 In Insured's Vehicle
 In Other Vehicle
 Age
Extent Of Injury (75 characters max)
Second Injury information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Phone
 Is Pedestrian
 In Insured's Vehicle
 In Other Vehicle
 Age
Extent Of Injury (75 characters max)
Third Injury information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Phone
 Is Pedestrian
 In Insured's Vehicle
 In Other Vehicle
 Age
Extent Of Injury (75 characters max)
Fourth Injury information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Phone
 Is Pedestrian
 In Insured's Vehicle
 In Other Vehicle
 Age
Extent Of Injury (75 characters max)

        Witness Information
First Witness Information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Phone
 In Insured's Vehicle
 In Other Vehicle
Other Location (75 characters max)
Second Witness Information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Phone
 In Insured's Vehicle
 In Other Vehicle
Other Location (75 characters max)
Third Witness Information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Phone
 In Insured's Vehicle
 In Other Vehicle
Other Location (75 characters max)
 Reported By
 Reported To

        Remarks
Remarks (300 characters max)

        Additional Remarks - Sheet 1
Additional Remarks Sheet 1 (Acord 101 Form - 3500 characters max)

        Additional Remarks - Sheet 2
Additional Remarks Sheet 2 (Acord 101 Form - 3500 characters max)

        Identification Code
 Code Description
 Code Value

        User Defined Fields
 User Defined Text 1
 Total Med Cost in $
User Description (100 characters max)
 User Defined Date 1
 User Defined Date 2
User Defined Comment (300 characters max)

        Report History
Report History (click to view or download)


 Release Status
 Release Date
 Release Actions
Release Comments (300 characters max)