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"Jim has our best interests in mind. He was able to save us many dollars on our car insurance. We are so grateful for his thoroughness and time spent with us to make sure we have the best plan for our needs."

~ Diana Beaudoin

Auto Loss

Insured
Name: Residence Phone: Business Phone:
Email:
Address: Apt:
City: State: Zip:
Contact Person: Where to Contact: When to Contact:
Residence Phone: Business Phone:
Loss
Location of Accident:
City: State: Zip:
Authority Contacted: Report #: Violations/Citations:
Description of Accident:
Insured Vehicle
Year: Make: Model:
VIN #: Plate #:
Owner's Name: Phone:
Owner's Address: Apt:
City: State: Zip:
Driver's Name: Business Phone: Residence Phone:
Driver's Address: Apt/Ste:
City: State: Zip:
Relation to Insured: Date of Birth: Driver's License #:
Purpose of Use: Used with Permission?
Yes No
Describe Damage: Estimate Amount:
Where can Vehicle be Seen? When?
Property Damaged
Describe Property: (if auto: year, make, model, plate no.)
Other Veh./Prop. Ins.? Company/Agency Name: Policy #:
Yes No
Owner's Name: Business Phone: Residence Phone:
Owner's Address: Apt:
City: State: Zip:
Other Driver's Name: Business Phone: Residence Phone:
Other Driver's Address: Apt:
City: State: Zip:
Describe Damage: Estimate Amount: Where can Damage be Seen?
Injured
Name: Phone: Age:
Address: Apt:
City: State: Zip:
Name: Phone: Age:
Address: Apt:
City: State: Zip:
Witnesses or Passengers
Name: Phone: Age:
Address: Apt:
City: State: Zip:
Name: Phone: Age:
Address: Apt:
City: State: Zip:

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