Sioux City Community School District Logo

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 *
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Insured Vehicle *
 Vehicle NumberYear, Make and ModelVIN (Vehicle ID)
Please complete
Owner's Name:
Sioux City Community School District
627 4th Street
Sioux City, IA 51101

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Property Damaged *
 Describe PropertyOther Vehicle or Insured Property
Please complete
Injured
 Name, Address, PhoneDescribe Injury
Please complete
Witnesses
 Name & AddressBusiness & Residence Phone
Please complete