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Automobile Loss Notice Form
Data Fields with a red border must be completed before FirstReport Online can create a new incident record.
Last Report Generated
(click to view or download)
Employer Name
Location Name
Department Name
FROL ID
Hidden Record ?
Record Marked for Delete ?
Basic Case Information
Report Number
Date Prepared
Date Of Loss
Time Of Loss
For Information Only
Claim Status
Open
Closed
Carrier Claim Number
First Incident Identifier
Second Incident Identifier
Agency Information
Name
Address 1
Address 2
City
State
Zip
Contact
Contact Phone
Fax
Contact Email
Agency Code
Agency Subcode
Customer ID
Insured Location Code
Carrier Name
Carrier NAICS
Policy Number
Policy Type
Insured Information
Name
Date of Birth
FEIN
Marital Status
Single
Married
Divorced
Separated
Widowed
Domestic Partner (Unmarried)
Civil Union
Unknown
Other
Primary Phone
Primary Phone Type
Home
Business
Cell
Secondary Phone
Secondary Phone Type
Home
Business
Cell
Address 1
Address 2
City
State
Zip
Primary Email
Secondary Email
Contact Information
Contact Insured
Yes
No
Name
Primary Phone
Primary Phone Type
Home
Business
Cell
Secondary Phone
Secondary Phone Type
Home
Business
Cell
When To Contact
Address 1
Address 2
City
State
Zip
Primary Email
Secondary Email
Loss Information
Address
City
State
Zip
Country
Police or Fire Department Contacted
Police or Fire Department Report Number
Description of Accident (150 characters max)
Insured Vehicle Information
Vehicle Number
Year
Make
Model
Body Type
VIN
Plate Number
State
Owner Is Insured
Yes
No
Owner Name
Owner Address 1
Owner Address 2
Owner City
Owner State
Owner Zip
Owner Primary Phone
Owner Primary Phone Type
Home
Business
Cell
Owner Secondary Phone
Owner Secondary Phone Type
Home
Business
Cell
Owner Primary Email
Owner Secondary Email
Driver Is Owner
Yes
No
Driver First Name
Driver Initial
Driver Last Name
Driver Address 1
Driver Address 2
Driver City
Driver State
Driver Zip
Driver Primary Phone
Driver Primary Phone Type
Home
Business
Cell
Driver Secondary Phone
Driver Secondary Phone Type
Home
Business
Cell
Driver Primary Email
Driver Secondary Email
Driver Relation To Insured
Insured
Spouse
Child
Sibling
Parent
Employee
Driver Date Of Birth
Driver License Number
Driver License State
Purpose Of Use
Used With Permission
Yes
No
Describe Damage (300 characters max)
Estimate Amount
Can Be Seen Where
Can Be Seen When
Other Carrier
Other Policy Number
Other Vehicle / Property Damaged Information
Non Vehicle Damage
Yes
No
Vehicle Number
Year
Make
Model
Body Type
VIN
Plate Number
State
Describe Property (100 characters max)
Is Property Insured
Yes
No
Carrier Name
Carrier NAICS
Policy Number
Owner Name
Owner Address 1
Owner Address 2
Owner City
Owner State
Owner Zip
Owner Primary Phone
Owner Primary Phone Type
Home
Business
Cell
Owner Secondary Phone
Owner Secondary Phone Type
Home
Business
Cell
Owner Primary Email
Owner Secondary Email
Driver Is Owner
Yes
No
Driver First Name
Driver Initial
Driver Last Name
Driver Address 1
Driver Address 2
Driver City
Driver State
Driver Zip
Driver Primary Phone
Driver Primary Phone Type
Home
Business
Cell
Driver Secondary Phone
Driver Secondary Phone Type
Home
Business
Cell
Driver Primary Email
Driver Secondary Email
Describe Damage (300 characters max)
Estimate Amount
Can Be Seen Where
Injury Information
First Injury information
Name
Address 1
Address 2
City
State
Zip
Phone
Is Pedestrian
Yes
No
In Insured's Vehicle
Yes
No
In Other Vehicle
Yes
No
Age
Extent Of Injury (75 characters max)
Second Injury information
Name
Address 1
Address 2
City
State
Zip
Phone
Is Pedestrian
Yes
No
In Insured's Vehicle
Yes
No
In Other Vehicle
Yes
No
Age
Extent Of Injury (75 characters max)
Third Injury information
Name
Address 1
Address 2
City
State
Zip
Phone
Is Pedestrian
Yes
No
In Insured's Vehicle
Yes
No
In Other Vehicle
Yes
No
Age
Extent Of Injury (75 characters max)
Fourth Injury information
Name
Address 1
Address 2
City
State
Zip
Phone
Is Pedestrian
Yes
No
In Insured's Vehicle
Yes
No
In Other Vehicle
Yes
No
Age
Extent Of Injury (75 characters max)
Witness Information
First Witness Information
Name
Address 1
Address 2
City
State
Zip
Phone
In Insured's Vehicle
Yes
No
In Other Vehicle
Yes
No
Other Location (75 characters max)
Second Witness Information
Name
Address 1
Address 2
City
State
Zip
Phone
In Insured's Vehicle
Yes
No
In Other Vehicle
Yes
No
Other Location (75 characters max)
Third Witness Information
Name
Address 1
Address 2
City
State
Zip
Phone
In Insured's Vehicle
Yes
No
In Other Vehicle
Yes
No
Other Location (75 characters max)
Reported By
Reported To
Remarks
Remarks (300 characters max)
Additional Remarks - Sheet 1
Additional Remarks Sheet 1 (Acord 101 Form - 3500 characters max)
Additional Remarks - Sheet 2
Additional Remarks Sheet 2 (Acord 101 Form - 3500 characters max)
Identification Code
Code Description
Code Value
User Defined Fields
User Defined Text 1
User Defined Text 2
User Description (100 characters max)
User Defined Date 1
User Defined Date 2
User Defined Comment (300 characters max)
Export Data
Report Type
Incident
Report History
(click to view or download)
Release Status
Release Date
Release Actions
Release
Release Comments (300 characters max)