Tanenbaum Harber

Personal Auto Claim

Policy Holder
Please be sure to complete all of the requested information so that your agent may contact you after receiving this notification.
Named Insured::
Street Address:
City, State, Zip
Name of Contact/ Person Filing Claim
Phone Numbers: Work
Home
E-mail Address:
Fax Number
Details of Claim/Loss
Time & Date of Loss	Time AM PM Date
Location: (Number, Street, Intersection, etc.)
Detailed Description: (use additional comments below if necessary)
Were the Police Notified?	Yes No
Department?:
Case Number?:
Were You Ticketed or at fault?	Yes No
If Yes, explain?
Other Party Information If this claim involved another party, please provide us with as much information as possible
Name:
Address:
Phone:	Work
	Home
Automobile:	Yr.
	Make
	Model
Driver's License #:	State
License Plate #:	State
Their Insurance Company:
Their Policy Number:
Describe damage to the other car:
Where is the car now?

Additional Information In the box below, please provide any additional information you feel may be necessary for this Loss Notice form.

Submission of a loss notice does not represent, assure or guarantee that coverage will be provided by your insurance program. If information is required, you will be contacted by either a representative of Tanenbaum Harber or your insurance company.

Any person who knowingly, and with the intent to injure, defraud, or deceive a company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony and / or subject to criminal prosecution, civil penalties; punishable by imprisonment or fines.

I have read and agree with the above disclaimer (It is mandatory to check box before request can be sent)