Name: Preferred Insurance
Address: 4035 Ridge Top Road, Fairfax, VA, 22030, US
Telephone: (703) 359-5910

Insured
Company Name
Reported By
Date
MM slash DD slash YYYY
Daytime Phone Number
Email
Fax
Loss
Location
Date of Loss
MM slash DD slash YYYY
Time of Loss (e.g., 12:30 PM)
Police Department
Report Number
Accident Description
Additional Information
Injured
Name
Daytime Phone Number
Address
Transported to Hospital?
Fatality
Nature of Injury (if known)
Attach additional sheet if necessary
Max. file size: 59 MB.
Property Damage: Non-Auto
Owner
Address
Daytime Phone Number
Approximate Value $
Describe Damage
Please attach additional sheet if necessary
Max. file size: 59 MB.
Insured Vehicle
Year
Make/Model
VIN (Vehicle Identification Number)
Owner
Owner Daytime Phone Number
Driver
Driver Daytime Phone Number
Date of Birth
License Number
Describe Damage
Injuries
Other Vehicle
Year
Make/Model
VIN
Insurance Carrier
Policy Number
Address
Driver
Daytime Phone Number
Describe Damage
Injuries
Attachments
Max. file size: 59 MB.
Comments/Witness Information
Name
Phone Number
Additional Details
Office Use Only
Report Received by Agency
Report Submitted to Carrier
Please fax any additional information or the police report to our office at 703-359-5915.
Disclaimer: Communications to this insurance agency by electronic mail or voice mail CANNOT be considered as binding or otherwise effective for ANY insurance protection/policy coverage. Our office will contact you via e-mail to confirm any information sent and please look for the policy change endorsement to follow. If you do not receive this endorsement from the insurance carrier, contact your agent immediately. Thank you.

Loss Notice Form

Insured

Loss

Injured

Property Damage: Non-Auto

Insured Vehicle

Other Vehicle

Comments/Witness Information

Office Use Only