Auto Notice Of Loss Report  

For Clients of Bob Meyer & Miller-Hartwig Insurance Agency.    For accidents involving serious injuries, call your your insurance company, or Agent.

Your Name (Our Client):*

Street Address:*

City or Town:*

State:

MN WI

Zip Code:

Phone Number Home:

Telephone Work or Cell #:

Your Insurance Company Name:

Your Insurance Policy Number:

Driver of Your Vehicle:*

Driver of Your Veh - Their Address:

City where Driver Lives:

Date Of Loss:

Time Of Loss:

Location of Loss:

Description of Accident: Include direction of travel and position of vehicles just prior to incident:

Describe Type of Loss, (Theft, Hail, Windstorm, Hit and Run):

Police Contacted?:

Selection Required Not Contacted City Police Contacted Other Police Authority-detail below No Sure Other

Report Number if Known:

Other Police or Authority Contact:

Were any citations issued?:

Selection Required Yes No Not Sure

If Citations, give type if known:

Your Vehilce Year, Make, & Model, If Involved:

Vehicle License Number and/or VIN:

Describe any damage to your vehicle:

Where is your vehicle Now?:

Is your vehicle driveable?

Selection Required Yes No

OTHER vehicles involved? - VEHICLE # 1:

Selection Required No - Skip Other veh. questions Yes - Complete other vehicles section

Other Vehicle #1 - Year, Make, & Model:

Other Vehicle #1, VIN or License #:

Other Vehicle #1, License Number STATE:

Other Veh #1 Describe Damage: (If None indicate so):

Location of Other Vehicle #1:

Is Other veh #1 driveable?:

Yes No Not Sure

Other Veh # 1 Driver Name: (If other than Owner):

Other Veh #1 - Owners Name:

City, State, ZIP for Owner Of Other Vehicle #1:

Phone Number for Other Veh. Owner: (Home):

Phone Number for Other Veh. Owner (Work) or (Cell):

Drivers License Number for Driver Veh #1:

Licensed State:

Other Vehicle #1, Policy Owners Name:

Other Vehicle #1 - Insurance company:

Other Veh. #1 Insurance Policy #:

OTHER VEHICLE # 2 Year, Make, Model:

OTHER VEHICLE # 2 VIN or License Number:

OTHER VEHICLE # 2 License Number STATE:

OTHER VEH # 2:

Location of Other Veh # 2:

Is Other Veh # 2 driveable?

Yes No Not Sure

OTHER Veh # 2 Driver Name, (If other than Owner):

OTHER Veh # 2, Vehicle Owner, (Leave Blank if Same as Driver):

City, State, & Zip for Owner of Other Veh # 2:

Phone Number for Other Veh # 2, (Home):

Phone Number for Other Veh # 2, (Work or Cell):

Drivers License # for Driver of Veh # 2:

Drivers License State for Driver of Veh # 2:

OTHER Veh # 2, Policy Owners Name:

OTHER Veh # 2, Insurance Company

OTHER Veh # 2, Insurance Policy #:

Indicate and provide details if any other vehicles invloved:

Was anyone injured?

Yes No Severe Injuries, Call your insurer NOW. Unsure

Minor Injuries, Describe, give names and telephone numbers:

Witnesses of the Incident:

Your Email Address:*