Automobile Loss Notice 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: Vehicle ID Number: 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: Agency-Division Code: (334) 223-6120, FAX (334) 223-6282 State of Alabama Finance Department Division of Risk Management 777 S Lawrence Street Montgomery, Alabama 36104                                         Middle Initial: Agency-Division Name: Please select from one of the following listings: Email Address: Supervisor's Email Address: Supervisor/Fleet Cordinator Contacted: Fax Number:      
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