Hartland Insurance Agency, Inc. located in Hartland, MI We are a Trusted Choice insurance agency
Products About Us Forms Knowledge Area

Automobile Loss Notice

Fill in the information below and we will respond.
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:
Call Us Toll Free: 866-223-2112
© 2008 Hartland Insurance Agency
Website Design and Development by 3Sixty Interactive