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Auto Loss Notice Form

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 Buccaneer Insurance or your insurance company.

Please note that this form is for notification purposes only and does not constitute making an actual claim.

Contact Information
Full Name:
Company (if applicable):
Address:
City:
State:     Zip:
Daytime Phone:   Night Phone:
Best Time To Call:   AM   PM
E-mail Address:

Policyholder Information
Policy Number:

Check this box if Policyholder Name/Telephone matches "Contact Information".
If you checked the box above, please skip to "Accident Information", otherwise complete the questions in this shaded area.
Policyholder Name:
Daytime Phone:
Policyholder - Address:
Address (line 2):
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 or Questions

 

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