Civil Service Employees Auto Insurance
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Automobile Loss Notice
Company    
CSEICO CSE Safeguard
Policy Number    
Date of Loss (MM/DD/YYYY)   
Reported By    
AGENT    INSURED     OTHER
Name    
Phone
If "Other," please state     relationship to claim    
E-mail
Best time to contact
 
Insured
Name
Address
City
State
 
ZIP
 
Home/Cell Phone
Work Phone
E-mail
Best time to contact
  

ALTERNATE CONTACT    
YES NO

If we should contact someone other than the insured, please specify:
NAME
PHONE
E-mail
Best time to contact
  
Loss
WAS THE DRIVER AT TIME OF THE ACCIDENT THE INSURED?     YES NO
If answer is "No" please provide the driver's information:
Name    
Address    
City
State
ZIP    
 
Home/Cell Phone
Work Phone
E-mail   
INSURER OF DRIVER OF INSURED'S VEHICLE
POLICY NUMBER
LOCATION OF ACCIDENT (include city and state)
DESCRIPTION OF ACCIDENT
Where is the vehicle presently located?
Is the vehicle drivable?
YES NO
 
Insured Vehicle
YEAR
   MAKE
   PLATE #
   STATE
Was there one or more child car seats in the vehicle at the time of the accident?   
YES NO
If so, was the seat, or were the seats, occupied at the time of the accident?   
YES NO
DESCRIBE DAMAGE TO VEHICLE
WAS MORE THAN ONE VEHICLE INVOLVED?     YES NO
OTHER VEHICLE
YEAR
   MAKE
   PLATE #
   STATE
Was there one or more child car seats in the vehicle at the time of the accident?   
YES NO
If so, was the seat, or were the seats, occupied at the time of the accident?   
YES NO
DESCRIBE DAMAGE TO VEHICLE
OWNER OF OTHER VEHICLE
Name    
Address    
City
State
 
ZIP    
 
Home/Cell Phone
Work Phone
E-mail
Insurer
Policy Number
WAS OWNER THE DRIVER AT THE TIME OF THE ACCIDENT?     YES NO
If answer is "No" please provide the driver's information:
Name    
Address    
City
State
 
ZIP    
 
Home/Cell Phone
Work Phone
E-mail
Insurer
Policy Number
ANY INJURIES?     YES NO
IF YES, PLEASE DESCRIBE

WITNESSES OR PASSENGERS
Name    
Address    
City
State
 
ZIP    
 
Home/Cell Phone
Work Phone
E-mail
Comment
Name    
Address    
City
State
 
ZIP    
 
Home/Cell Phone
Work Phone
E-mail
Comment
REPORT FILED?     YES NO
AUTHORITY
REPORT #
CITATIONS

 

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