Auto Liability Loss

General Instructions

When submitting a report, please complete the entire Web Loss Report Form and provide all required information. Required fields are marked in bold.

  • You can open/close any section of this form at any time by clicking a gray section header below.
  • If the mandatory information is unknown at the time of your web submission, enter "unavailable" in any field requiring text.
    Enter only numerals (1, 2, 3, etc.) in all fields that require a number value.
  • The final report will depend on the accuracy and completeness of the information you are able to provide.
  • No information will be transmitted until you click the "submit" button at the bottom of the form.
  • The Accident Description field will have a 200-character limitation. Additional information can be entered in the final remarks area of the submission. Additional Remarks will have a 200-character limitation.

Emergencies

If your loss is severe, RISCOM recommends that you phone in your loss to insure that it receives the immediate attention it needs.

General Information >>
1. Date & Time of Accident
Date of Accident: (MM/DD/YYYY)      Time of Accident:  
2. Person Reporting
First Name:      Last Name:
Telephone Number: - -      Secure Fax Number: - -
Relationship to Accident:
I am a(n) (choose one):
3. Insured Information
Insured Name:
Insured DBA (Doing Business As) Name:
Address:
City:     State: '      Zip: -   
Telephone Number: - -      Contact Name:
Policy Number:       Effective Date: (MM/DD/YYYY)
Agent Name:
Location Information >>
4. Loss Location Information
Location Name:
Address:
City:     State:      Zip: -   
Date Insured Was Notified: (MM/DD/YYYY)      Time Insured Was Notified:  
Insured Driver & Vehicle >>
5. Type of Accident/Damage
Type of Accident/Damage:
With Other Vehicle     With Property     With Pedestrian      With Animal      Insured Vehicle only
     Other, Explian
6. Insured Driver Information
'
(Note: enter "unavailable" if insured driver's name is not available)
First Name:      Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Gender:      Marital Status:      Date of Birth: (MM/DD/YYYY)
Age:      Driver's License Number:      State:
Relation to Insured:
Purpose of Use:      Used with Permission:
Accident Description:
7. Insured Vehicle Information
Year:      Make:      Model:     Body Type:
Vehicle Identification Number (VIN):      Vehicle/Fleet #:
Plate #:      State:
Damage Description:    Can Vehicle be Driven:
Estimated Amount of Repairs:      Where Vehicle Can Be Seen:
Other Driver & Vehicle 1 >>
8. Other Driver Information 1
First Name:     Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Driver's License Number:      State:
9. Other Vehicle Information 1
Year:      Make:      Model:     Body Type:
Plate #:      State:
Insurance Company:      Policy Number:
Damage Description:    Was vehicle towed from scene:
Other Driver & Vehicle 2 >>
10. Other Driver Information 2
First Name:     Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Driver's License Number:      State:
11. Other Vehicle Information 2
Year:      Make:      Model:     Body Type:
Plate #:      State:
Insurance Company:      Policy Number:
Damage Description:    Was Vehicle Towed from the scene:
Property Information >>
12. Property Information
(Note: If corporation, put name in last field)
First Name:     Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Damage Description:
Estimated Amount of Damages:
Injury Information >>
13. Injury Information
Injured:      Fatality Involved:      Total Number of Injuries:     
Number Injured in Insured Vehicle:     Number Injured in Other Vehicle:     
Number of Pedestrian:
First Name:     Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Age:      Type of Claimant:
Injury Description (include body part and type of injury):   Transported from scene by ambulance :
14. Additional Injured 1
First Name:     Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Age:      Type of Claimant:
Injury Description (include body'part and type of injury):   Transported from scene by ambulance :
15. Additional Injured 2
First Name:     Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Age:      Type of Claimant:
Injury Description (include body part and type of injury):   Transported from scene by ambulance :
Witness Information >>
16. Witness Information
Were There Any Witnesses to the Incident:
First Name:     Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Type:
Second Witness
First Name:     Last Name:
Address:
City:     State:      Zip: -
Telephone Number: - -
Type:
Closing Information >>
17. Contact Information
First Name:      Last Name:
Telephone Number: - -     Cell Phone Number: - -
Your Email Address:
If you wish to receive a claim acknowledgement, please enter a secure fax number to send to: - -
18. Additional Remarks
Enter any additional remarks you would like to make in the space below: