Automobile Loss Notice

Producer:

AJ Gallagher

4280 Sergeant Rd, Ste 200

Sioux City, IA 51106

712-585-4026

Company:

Employers Mutual

PO Box 884

Des Moines, IA 50304

Insured:

Sioux City Community School District

627 4th Street

Sioux City, IA 51101

Contact:

Troy Thomas

712-279-6666

thomast@live.siouxcityschools.com

Location *

	-	-
-	-	-

Authority contacted *

Violations/Citations *

Insured Vehicle *

	Vehicle	Year/Make	VIN #
Please complete	Vehicle	Year/Make	VIN #

Owner's Name:

Sioux City Community School District

627 4th Street

Sioux City, IA 51101

Owner's Phone Number

Driver's Name *

Driver's Phone Number *

Relation to Insured *

Date of Birth *

Driver's License Number *

Purpose of Use

Used with Permission? *

Describe Damage *

Estimate Amount *

Date of Accident: *

Time of Accident: *

Where can vehicle be seen? *

When? *

Save & Return

Save your progress and complete this form later. (optional)

Property Damaged *

	Describe Property	Other Vehicle or Insured Property
Please complete	Describe Property	Other Vehicle or Insured Property

Insurance Company or Agency Name *

Policy Number *

Owner's Name and Address *

Owner's Business Phone *

Owner's ResidencePhone *

Other Driver's Name and Address *

Other Driver's Business Phone *

Other Driver's Residence Phone *

Describe Damage *

Estimate Amount *

Where can damage be seen *

Injured

	Name, Address, Phone	Describe Injury
Please complete	Name, Address, Phone	Describe Injury

Witnesses

	Name & Address	Business & Residence Phone
Please complete	Name & Address	Business & Residence Phone

Remarks

Reported by: *

Reported to: *