frmAutoLossNotice

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? Yes No Citations? Case Number: What: Police Department: Name: Who: Telephone: Name: Address: Witness Information: Police Information: Prevention/Remarks: Yes Yes Yes Yes Yes No No No No No Yes Yes Yes Yes Yes No No No No No Insured Vehicle: Injured? Other Vehicles: Injured? Please List Names Of All Occupants In All Vehicles Involved In Accident: Occupants: Phone: Yes No Policy Number: Company Name: Other Driver's Insurance? If Yes, Please Describe Injury: Yes No 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: Yes No 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: Yes No 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 *Invalid Zip Code *Limit Field to 300 Characters *Invalid Phone # *Invalid Date use mm/dd/yyyy *Invalid Time *Limit Field to 300 Characters *Limit Field to 300 Characters *Invalid Amount * Invalid input for Damage * Invalid Home # * Invalid Work # * Invalid Zip Code * Invalid Phone # * Invalid Phone Number * Invalid Phone Number * Invalid Phone Number * Invalid Phone Number *Limit Field to 300 Characters * Invalid Date * Invalid Phone # Middle Initial: Agency Name: Division Code: Please select from one of the following listings: Email Address: Supervisor's Email Address: Supervisor/Fleet Cordinator Contacted: Yes No Fax Number: * Please choose a department by selecting their Agency Code or Agency Name. * Please enter First Name. * Please enter Last Name. * Please enter driver's street address. * Please enter driver's phone number. * Please enter driver's license number. * Please enter specific duty being performed. * Please enter date of accident. * Please enter accident city. * Please enter accident street name. * Please enter accident county name. * Please enter accident highway. * Please describe accident. * Please VIN. * Please enter vehicle make. * Please enter vehicle model. * Please enter accident county name. * Please enter covered vehicle tag number. * Please enter police department name. *Invalid Phone # * Invalid Fax #

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