If you would prefer... you can call your claim in directly to several of our companies.  The numbers are listed below:

• A. Central  800 607-7686

• AIG  888 244-6131

• Farmers 800 435-7764

• Foremost  800 527-3907

• GMAC  800 526-0332

• National Grange  877 425-2667

• OneBeacon  800 962-7277

• Progressive  800 274-4499

• Safeco/American States  888 557-5010

• Utica National  800 274-1914

Time and Location of Accident
Time & Date of Accident	Time a.m. p.m.     Date
Location of Accident: (Number, Street, Intersection, city, etc.)
Description of the Accident:

Your Vehicle Information
What car were you driving?	Yr.   Make   Model >
License Plate #:	State
Is this your car?	Yes     No
If No, were you using it with permission?	Yes     No     Please explain below:
Was There Damage Done to your vehicle?	Yes     No
If Yes, please describe:
Where can the vehicle be seen:

Other Driver Information
Name:
Address:>
Phone:	Work     Home
Automobile:	Yr.   Make   Model
Driver's License #:	State
License Plate #:	State
Insurance Company:
Describe damage to other vehicle:
Where can car be seen?

Injuries, Witnesses, Etc.
If there were any Injuries, please describe:
Please list any Witnesses and/or Passengers:	(Please include Name, Address and Phone #)

Police Notification
Were the Police Called?	Yes     No
What Authority?
Were You Ticketed?	Yes     No
If Yes, what for?

Report Information
Reported by:
Title (if any):
Date:

Additional Comments

Please provide any additional comments you feel appropriate for this Loss Notice.

If you feel dissatisfaction at any time, please do not hesitate to let us know.  We are here to assist you until your claim is settled to your satisfaction!