Warren G. Bender Co. - Insurance&Bonds

WG Bender Insurance Company

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Commercial Automobile Loss Notice

Items marked with * are required to process this form correctly.
	Insurance Company:
	Policy Number:
*	Date of Loss:
*	Time of Loss:
	Insured's Information
*	Name:
	Address:
	City:
	State:
	Zip:
	Residence Phone:
*	Business Phone:
*	Email:
*	Person to Contact:
	Loss
*	Location of Accident (including City & State):
	Authority Contacted:
	Report Number:
*	Description of Accident:
	Insured Vehicle
*	Year:
*	Make:
*	Model:
*	V.I.N (Vehicle ID No.) :
	Plate No.:
	Driver's Name:
	Driver's Address:
	City:
	State:
	Zip:
	Driver's License Number:
	Used with Permission?
	Describe Damage:
	Estimate Damage Amount:
*	Where can Vehicle be seen?
	Other Party Information
	Describe Property - (if auto, year, make, model, plate no.)
	Other Vehicle/Property Insurance?
	Company or Agency Name:
	Policy Number:
	Owner's Name:
	Owner's Address:
	City:
	State:
	Zip:
	Business Phone:
	Residence Phone:
	Driver's Name:
	Driver's Address:
	City:
	State:
	Zip:
	Describe Damage:
	Estimate Amount:
	Injured
*	Any injured?
	Injured 1
	Name: (If minor, Name of Parent)
	Address:
	City:
	State:
	Zip:
	Phone:
	Extent of Injury:
	Injured 2
	Name: (If minor, Name of Parent)
	Address:
	City:
	State:
	Zip:
	Phone:
	Extent of Injury:
	Injured 3
	Name: (If minor, Name of Parent)
	Address:
	City:
	State:
	Zip:
	Phone:
	Extent of Injury:
	Injured 4
	Name: (If minor, Name of Parent)
	Address:
	City:
	State:
	Zip:
	Phone:
	Extent of Injury:
Witnesses or Passengers
*	Any witnesses or passengers?
	Witness/Passenger 1
	Name:
	Address:
	City:
	State:
	Zip:
	Phone:
	Witness/Passenger 2
	Name:
	Address:
	City:
	State:
	Zip:
	Phone:
	Witness/Passenger 3
	Name:
	Address:
	City:
	State:
	Zip:
	Phone:
	Witness/Passenger 4
	Name:
	Address:
	City:
	State:
	Zip:
	Phone:
	Remarks:
	Reported By
*	Name:
	Address:
*	Phone: