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AUTOLOSS NOTIFICATION

POLICY HOLDER INFORMATION
Please be sure to supply all if your contact information so we
may promptly contact you after receiving this notification.
Name of Insured:
Address:
Phone #: Work     Home
Email:
TIME AND LOCATION OF ACCIDENT/LOSS
Time & Date of Loss
Time a.m.
p.m.		     Date
Location of Accident:
(Number, Street, Intersection, etc.)
Description of Accident:
POLICE NOTIFICATION
Were the Police Notified? Yes     No
What Authority?
Were You Ticketed? Yes     No
If Yes, what for?
YOUR VEHICLE INFORMATION
Damage to your vehicle? Yes     No
If Yes, describe:
Where can the vehicle be seen:
What vehicle were you driving? Yr.   Make   Model
License Plate #:   State
Is this your vehicle? Yes     No
If No, were you using it with permission? Yes     No     Please explain below:
OTHER DRIVER INFORMATION
Name:
Address:
Phone: Work     Home
Vehicle: 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 REPORT INFORMATION
Reported by:
Title (if any):
Date:
ADDITIONAL COMMENTS
Please give any additional comments regarding this Loss Notice.

DISCLAIMER:

I understand that by completing this form it does not constitute an actual
claim, but is rather a notification to my agent of an existing loss or claim,
and may help expedite the claim process once I have filed.


One of our representatives will respond to your submission as soon as possible.



Copyright © 2003 by InsuranceNewsNet

AUTOMOBILE POLICY CHANGE REQUEST

POLICY HOLDER INFORMATION
Name Of Insured:
Phone Number:     E-Mail:
Effective Date
of Change:
IF ADDING A VEHICLE:
Year:     Make
Model:     Serial #:
Cost: $
Anti-Lock Brakes: 0     1     2
Air Bags: None     Driver     Driver/Passenger
Anti-Theft Device: Yes     No
How will car
be driven?
(Check One):
Business Pleasure     To/From Work    
Farm Car Pool    
IF ADDING A DRIVER:
Full Name:
Relationship:     DL#:
Date of Birth:     SS#:
Defensive Driving
Certificate?		 Yes     No
Drivers Training
Certificate?		 Yes     No
IF DELETING A VEHICLE:
Effective Date
of Change:
Year:     Make:
Model:     Serial #:
IF DELETING A DRIVER:
Name:
Reason:


Please click on the "Submit Form" button to send your Auto Policy Change.
One of our representatives will respond as soon as possible.

Copyright © 2003 by InsuranceNewsNet

 

YOUR "ONE SOURCE SOLUTION" FOR ALL YOUR BUSINESS NEEDS

Kite Insurance Agency LLC
304 W. Cervantes St., Pensacola, FL 32501
Phone: 850-438-0008 - FAX: 888-611-6979

Hours of Operation:

Monday - Thursday 9:00 a.m. - 5:00 p.m.

Friday 9:00 a.m - 1:00 p.m.

Closed for Lunch 12 -1