Summit Insurance - Automobile Loss Notice

Automobile Loss Notice

This is a claim form. Please enter the information requested below. All fields are required unless otherwise noted.
If you would like a printable form that you can mail or fax to us, please choose a version to download: English Spanish


Name of Person Completing Report				Email Address		Verify Email Address
Company Name			Address			City, State, (Zip)
Loss Location (if different than address)					Date of Loss
Type: Collision, Property Damage, Injury, Death					Time of Loss, AM or PM

Insured Automobile
Driver		Vehicle Number (VIN)		Year	Make	Model	Damage Area
Address, City, State, Zip				Phone		Driver's License #, State
Passengers			Injuries			Vehicle Drivable Yes No

Accident Description
Include street names and direction of travel. You are vehicle #1:

Other Involved Parties
Vehicle 2 VIN	Driver			Year	Make	Model	Damage Area
Address, City, State, Zip				Phone		Owner (if different)
Passengers			Injuries			Vehicle Drivable Yes No
Driver's License #, State		Insurance Company			Policy Number
Vehicle 3 VIN	Driver			Year	Make	Model	Damage Area
Address, City, State, Zip				Phone		Owner (if different)
Passengers			Injuries			Vehicle Drivable Yes No
Driver's License #, State		Insurance Company			Policy Number
Other Contributing Causes: i.e. weather, intoxication, animal, mechanical failure, road work
Witnesses
Authority Contacted				Violations
Report Number
Is this a Questionable Accident? Yes No
Subrogation: Is any person, company, or machinery responsible for loss: Yes No				If you answered Yes to the last question, please give details:
Any additional information: