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					ACORD                           AUTOMOBILE LOSS NOTICE                         DATE (MM/DD/YY):    11/6/11


POLICY NUMBER:                WINS POLICY NUMBER:

EFFECTIVE         EXPIRATION             DATE OF ACCIDENT AND
DATE              DATE                   TIME


INSURED                                            CONTACT INSURED
NAMED AND ADDRESS:                                 NAME:

                                                   BUSINESS PHONE:



LOSS
LOCATION:                                                    AUTHORTIY CONTACTED:          VIOLATION/CIATIONS:
OF ACCIDENT:
(STATE):                                                     REPORT #:
DESCRIPTION OF ACCIDENT:

INSURED VEHICLE
VEH #        YEAR           MAKE:                         VIN:                     NOTICE ONLY


DRIVER’S NAME & ADDRESS:                                         RESIDENCE PHONE :
                                                                 BUSINESS PHONE :

CLAIMANT PROPERTY DAMAGE
OWNER NAME:                                                                          RESIDENCE PHONE (A/C. No.)

DRIVER NAME:
ADDRESS:                                                                             BUSINESS PHONE (A/C No. Ext)
CITY STATE:


DESCRIBE PROPERTY                            OTHER VEH/PROP INS?                     COMPANY OR
(If auto year, make, model, plate #):         YES      NO                            AGENCY NAME:

                                                                                     POLICY #:
DESCRIBE Damage:                                ESTIMATE AMOUNT:                 WHERE CAN DAMAGE
                                                                                 BE SEEN:
INJURED YES      NO
NAME                                    PHONE (A/C, No)      M/F   INS   OTH        AGE    EXTENT OF INJURY
                                                                   VEH   VEH



WITNESS OR PASSENGERS
NAME                                    PHONE (A/C, No)                  INS VEH     OTH         OTHER (Specify)
                                                                                     VEH


REMARKS (Include adjuster assigned)
REPORTED BY:                        REPORTED TO: Erin Franks

				
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posted:11/7/2011
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