Automobile Loss Notice * Required Field Middle Initial: Last Name: Include First and Last Name Include First and Last Name Include First and Last Name Include First and Last Name Use format 22222 or 22222-1111 Use format 11/25/2004 Use format 11/25/2004 Use format (555)555-5555 Use format 1:30pm OR 11:30am Use format 22222 or 22222-1111 Use format (555)555-5555 Use format (555)555-5555 Use format (555)555-5555 Use format (555)555-5555 Use format (555)555-5555 Use format (555)555-5555 State: Driver's Name: Fleet Coordinator's Name: Date: Telephone: What Action has or will be Taken to Prevent Recurrence? Citations? Case Number: What: Police Department: Name: Who: Telephone: Name: Address: Witness Information: Police Information: Prevention/Remarks: Insured Vehicle: Injured? Other Vehicles: Injured? Please List Names Of All Occupants In All Vehicles Involved In Accident: Occupants: Phone: Policy Number: Company Name: Other Driver's Insurance? If Yes, Please Describe Injury: Was Driver Or Passenger Injured? Zip: State: City: Address: Phone (Home): (Work): First Name: Other Driver: Estimated Amount Of Damage: Body Type: Year: Model: Make: Describe Vehicle: Describe Nature Of Damage : Damage To Other Property: Describe Area Damaged On Vehicle: Estimated Amount Of Damage: Tag Number: Body Type: Year: Model: Vehicle Owned By State? If No, Specify Ownership: VIN: Make: Covered Vehicle: City: Street Name: Highway: County Name: Date Of Accident: Time: Location: Describe Accident: Accident Information: Co. Phone Number: Policy Number: Company Name: Other Auto Insurance? Zip: State: City: Last Name: Covered Driver: . Agency Name: Agency Code: Job Title: Phone Number: First Name: Driver's Street Address: Driver's License No: Specific Duty Being Performed: Claim No: (334) 223-6120, FAX (334) 223-6282 We must have an accurate VIN and tag number to verify coverage for state owned vehicles. Please secure all required information before completing this form. State of Alabama Finance Department Division of Risk Management 777 S Lawrence Street Montgomery, Alabama 36104 Middle Initial: Agency Name: Division Code: Please select from one of the following listings: Email Address: Supervisor's Email Address: Supervisor/Fleet Cordinator Contacted: Fax Number:
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