First Volunteer Insurance Agency - insurance and banking for Tennessee, Northern Alabama and Northern Georgia!

	Auto Loss Report Claim Form

Insurance Company	Policy Number	Effective Date	Expiration Date

INSURED

CONTACT


Name		Name		Where to
Address		Address		Contact
City		City
State	Zip	State	Zip	When to
Home Phone		Home Phone		Contact
Work Phone		Work Phone

Date of Loss Time of Loss AM PM Previously Reported Yes No

LOSS

Location of Accident

Authority Contacted & Report Number

Violations / Citations

DESCRIPTION OF ACCIDENT

Policy Information

Bodily Injury	Property Damage	Single Limit	Med. Pay	Other Than Coll. Ded.	Collision Ded.

Other Coverages & Deductibles (No Fault, Towing, etc...)

Loss Payee

Insured Vehicle

INSURED VEHICLE

Year

Make

Model

Body Type

V.I.N.

Plate #

State

Owner Name		Address		City

State		Zip		Home Phone		Work Phone

Driver Name (check if owner)		Address		City

State		Zip		Home Phone		Work Phone

Relation to Insured		D.O.B.		Drivers License #		State		Purpose of Use		Used with Permission
										Yes No

Describe Damage		Estimate Amount
		$

Where can vehicle be seen		When can vehicle be seen		Other Insurance on vehicle

Property Damaged

Describe Property (if auto, yr, make, mdl, plate#)		Other veh/prop Ins.?		Company/Agency		Policy #
		Yes No

Owners Name		Address		City

State		Zip		Home Phone		Work Phone

Other Driver Name (check if same as owner)		Address		City

State		Zip		Home Phone		Work Phone

Describe Damage		Estimate Amount		Where can Damage be Seen
		$

Injured

	Name & Address	Phone	PED	INS VEH	OTH VEH	Age	Extent of Injury
1
2

Witnesses Or Passengers

	Name & Address	Phone	INS VEH	OTH VEH	Other (Specify)
1
2

REPORTED BY:	REPORTED TO:

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The insurance products that First Volunteer Insurance Agency, Inc. offers our customers and customers of First Volunteer Bank are: *Not a deposit *Not FDIC Insured *Not Insured by any Federal Government Agency *Not Guaranteed by the Bank *May Go Down in Value

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