Insured Name Contact Name

Date of Loss Time of Loss

Location of Loss (City & State)

Authorities Contacted? Yes No Accident Report Issued? Yes No

Driver's Name Driver's Address

Driver's Telephone Number

*Enter Vehicle Description Below

Tractor (Year, Make & Serial #)

Trailer (Year, Make & Serial #)

*Other Party Information

Owner's Name Address

Other Party's Telephone Number

Other Driver's Name (if different from Owner)

Vehicle Description (Year, Make & Serial #)

Insurance Company & Phone Number

Description of Loss

Injuries

Witness

This info reported by (your name)