Automobile Loss Claim - Amynta Group

Date

Name Of Agency*

Reported By*

First Last

Phone

Email

Insured Business Name

Address

Street Address City State ZIP Code

Phone

Fax

Email

Date Of Loss

Time Of Loss

:

Insurance Carrier

Policy Number

Name Of Contact

First Last

Phone

Email

When To Contact

Loss

Location Of Loss

Street Address City State ZIP Code

Police Or Fire Department Contacted

Yes
No

Report Number

Describe Location Of Loss If Not At Specific Street Address

Describe Accident

Insured Vehicle

VIN #

Year

Make

Model

Type

New
Used
Customer
Demo

Owner's Name And Address Is The Same As Insured

Yes
No

Owners Name (if different than insured)

First Last

Owner's Address (if different than insured)

Street Address City State ZIP Code

Owner's Phone (if different than insured)

Owner's Email

Driver's Name

First Last

Driver's Phone

Driver's Email

Relation To Insured (employee, family, etc. )

Occupation

Date Of Birth

Driver's License Number

State

Used With Permission

Yes
No

Purpose Of Use

Describe Vehicle Damage

Where Is Vehicle Located

Is Vehicle Drivable

Yes
No

Estimate Amount

Where Can Vehicle Be Seen?

When Can Vehicle Be Seen?

Other Insurance On Vehicle - Carrier

Policy Number

Other Vehicle/Property Damaged

Vehicle, Year, Make, and Model

Describe Property (Other than vehicle)

Carrier Or Agency Name

Policy Number

Owner's Name

First Last

Owner's Phone

Other Vehicle Driver's Name

First Last

Injuries

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Email

Age

Extent Of Injury

Witnesses Or Passengers

Name

First Last

Address

Street Address City State ZIP Code

Phone

Email

Remarks

Consent*

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Email

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Guardsman Claims - Automobile Accident

Loss

Insured Vehicle

Other Vehicle/Property Damaged

Injuries

Witnesses Or Passengers