Auto Loss Notice Form - The Zutz Group

Contact Information
Full Name:
Address:
City:
State:	Zip:
Daytime Phone:	Night Phone:
E-mail Address:

Policyholder Information
Policy Number:
	Check this box if Policyholder Name/Telephone Number matches "Contact Information".
If you checked the box above, please skip to "Accident Information", otherwise complete the remaining questions in this section area.
Policyholder Name:
Daytime Phone:
Policyholder - Address:
Policyholder - City:
Policyholder - State:	Zip:

Accident Information
Date of Accident:
Time of Accident:
Accident Location - Address:
Accident Location - City:
Accident Location - State:	Zip:
Location of Accident:
Description of Accident:
Police/Fire Contacted?:	Yes No
Police Report Number:
Police Department Name:
Any Witnesses Present?:	Yes No
Did Injuries Result from Accident?:	Yes No
If there were injuries, please provide Name, Address, Phone Number and Extent of the Injuries in the box below.

Damage Information
Was Your Vehicle Damaged?	Yes No
If your vehicle was damaged, complete the questions in this shaded area.
Vehicle Year
Vehicle Make
Vehicle Model
Describe the Damage to the Vehicle:
Where can the Vehicle be Seen?: (give address or phone number if known)
Describe Damage to Other Vehicles:
Describe Damage to Other Property (if applicable) :

Other Involved Parties

Provide contact and vehicle information for ALL parties involved in the accident.

Additional Comments

Submission of a loss notice does not represent, assure or guarantee that coverage will be provided by your insurance program. If further information is required, you will be contacted by either a representative of The Zutz Group or your insurance company.

Any person who knowingly, and with the intent to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is: guilty of a felony and/or subject to criminal prosecution, civil penalties; punishable by imprisonment or fines.

Please click the "Submit Claim" button to send your request.

		Legal & Privacy Statement Site Map Copyright © 2005 Zutz Insurance Group, All Rights Reserved The Zutz Group is licensed to provide Property and Casualty Insurance in all states except AK and HI.
		design by Squid Internet