Business
Auto Loss Report

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Business Auto Loss Report Form

Insured Information

Loss

Policy Information

Yes    No

Property Damage


(if applicable)

(If auto - year, make, model, plate#)


Injured


(if applicable)
1    2    3

Injured One

Injured Two

Others Injured

Witnesses or Passengers


(if applicable)
1    2    3

Witness or Passenger One

Witness or Passengers Two

Other Witnesses or Passengers


Insurance coverage cannot be bound or changed via submission of the online form/application, email, voice mail, text, or facsimile. You will be contacted by a licensed insurance agent with confirmation of your request.

* = Required

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