ACORD ™

AUTOMOBILE LOSS NOTICE

DATE

PRODUCER
PHONE: (A/C, No, EXT)
CODE:
SUBCODE:
AGENCY CUSTOMER ID:

COMPANY NAIC CODE:		MISCELLANEOUS INFO (Site & location code)
POLICY NUMBER	POLICY TYPE	REFERENCE NUMBER	CAT #
EFFECTIVE DATE	EXPIRATION DATE	DATE OF LOSS AND TIME AM PM	PREVIOUSLY REPORTED YES NO

INSURED

LOCATION OF ACCIDENT (Include city & state)	AUTHORITY CONTACTED: REPORT #:		VIOLATIONS/CITATIONS
DESCRIPTION OF ACCIDENT

POLICY INFORMATION

BODILY INJURY (Per Person)	BODILY INJURY (Per Accident)	PROPERTY DAMAGE	SINGLE LIMIT	MEDICAL PAYMENT	OTC DEDUCTIBLE	OTHER COVERAGE & DEDUCTIBLES (UM, no-fault, towing, etc)

LOSS PAYEE					COLLISION DED
UMBRELLA/EXCESS		UMBRELLA	EXCESS	CARRIER:
LIMITS	AGGR PER	CLAIM/OCC	SIR/DED

INSURED VEHICLE

VEH #	YEAR	MAKE:	BODY TYPE:		PLATE NUMBER	STATE
		MODEL:	V.I.N.:
OWNER'S NAME & ADDRESS				RESIDENCE PHONE (A/C No):
OWNER'S NAME & ADDRESS				BUSINESS PHONE (A/C No):
DRIVER'S NAME & ADDRESS Check if same as owner				RESIDENCE PHONE (A/C No):
DRIVER'S NAME & ADDRESS Check if same as owner				BUSINESS PHONE (A/C No):

RELATION TO INSURED (Employee, family, etc.)	DATE OF BIRTH	DRIVER'S LICENSE NUMBER	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 DAMAGEDVEHICLE YES NO

DESCRIBE PROPERTY (If auto, year, make, model, plate #)	OTHER VEH/PROP INS? YES NO	COMPANY OR AGENCY NAME:
DESCRIBE PROPERTY (If auto, year, make, model, plate #)	OTHER VEH/PROP INS? YES NO	POLICY #:
OWNER'S NAME & ADDRESS		RESIDENCE PHONE (A/C No):
OWNER'S NAME & ADDRESS		BUSINESS PHONE (A/C No):
DRIVER'S NAME & ADDRESS Check if same as owner		RESIDENCE PHONE (A/C No):
DRIVER'S NAME & ADDRESS Check if same as owner		BUSINESS PHONE (A/C No):

DESCRIBE DAMAGE	ESTIMATE AMOUNT	WHERE CAN DAMAGE BE SEEN?

INJURED

NAME & ADDRESS	PHONE (A/C, No)	PED	INS VEH	OTH VEH	AGE	EXTENT OF INJURY

WITNESSES OR PASSENGERS

NAME & ADDRESS	PHONE (A/C, No)	INS VEH	OTH VEH	OTHER (Specify)
			>

REMARKS (Include adjuster assigned)

REPORTED BY

REPORTED TO

SIGNATURE OF INSURED

SIGNATURE OF PRODUCER

Applicable in Arizona
For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Applicable in Arkansas, District of Columbia, Kentucky, Louisiana, Maine, Michigan, New Jersey, New Mexico, New York, Pennsylvania, Tennessee and Virginia
Any person who knowingly and with intent to defraud any insurance company or another person, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and [NY: substantial] civil penalties. In DC, LA, ME, TN and VA, insurance benefits may also be denied.

Applicable in California
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Applicable in Colorado
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Applicable in Florida and Idaho
Any person who Knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim Containing any False, Incomplete or Misleading information is Guilty of a Felony.*
* In Florida - Third Degree Felony

Applicable in Hawaii
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Applicable in Indiana
A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

Applicable in Minnesota
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

Applicable in Nevada
Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.

Applicable in New Hampshire
containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

Applicable in Ohio
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Applicable in Oklahoma
WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

ACORD 2 (2002/01)