Automobile Loss NoticeMiddle Initial:Last Name:Include First and Last NameInclude First and Last NameInclude First and Last NameInclude First and Last NameUse format 22222 or 22222-1111Use format 11/25/2004Use format 11/25/2004Use format (555)555-5555Use format 1:30pm OR 11:30amUse format 22222 or 22222-1111Use format (555)555-5555Use format (555)555-5555Use format (555)555-5555Use format (555)555-5555Use format (555)555-5555Use format (555)555-5555State: 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) 223-6282State of AlabamaFinance DepartmentDivision of Risk Management777 S Lawrence StreetMontgomery, 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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