ACORD Forms : How to Complete an Auto Loss Notice form 2Automobile Loss Notice 2
Use the ACORD Automobile Loss Notice (ACORD 2) for the reporting of both commercial and personal lines automobile losses.
Month/day/year on which the form is completed.
Phone (A/C, No, Ext)
Producer's telephone number.
Producer's fax number.
Producer's name and address.
Identification code assigned to your agency or brokerage firm by the insurance company receiving this form.
If your agency uses a sub-code identification system with the company, enter the appropriate code.
Agency Customer ID
Customer's identification number assigned by the agency.
Name of the applicable insurance company and its' NAIC code. Do not use group names, use the actual name of the company within the group to which you are sending the loss notice.
Use this field to list site and location codes for large accounts. It may also be used to enter the claim number on a phone-in report.
Number assigned by the insurance company for the policy.
Provide the type of policy issued to the insured. E. g., personal auto, truckers, garage liability.
Insured's claim number or other reference number to identify this notice.
If a catastrophe number has been assigned by the Property Claim Service or other industry organization, enter it here. This is the number assigned to the event that caused the loss being described.
Date on which the terms and conditions of the policy commenced.
Date on which the terms and conditions of the policy will or have expire(d).
Date of Accident and Time
Enter the date and approximate time the loss occurred. The appropriate A.M. or P.M. box should be checked (e.g, 01/11/94 - 12:15 A.M.).
Indicate if this is the first report on the loss that has been given to the company, whether written or by telephone. If not, list in the remarks section when other report(s) have been made.
Name & Address
Name, mailing address and social security number (or Federal Employer Identification Number (FEIN) if applicable,) of the insured as found on the declarations page of the policy.
Residence Phone (A/C, No)
For an individual, the home telephone number, including area code, at which the insured may be reached.
Business Phone (A/C, No, Ext)
Business telephone number, including area code and extension, of the insured.
If the individual to contact is the same as the insured, check this box and leave blank the areas for contact name, address and phone numbers.
Name and Address
Name and address of the individual who is to be contacted as a representative of the insured on all subsequent business relating to this incident. No entry is necessary if the "Contact Insured" option is checked.
Enter the home phone number including area code of the contact named above. If it is the insured, leave this field blank.
Enter the business telephone number, including area code and extension of the contact. If it is the insured, leave this field blank.
Where to Contact
Indicate where this person should be contacted (e.g., home, office, hospital).
Indicate the best time of the day to contact this individual (e.g., evenings, days, noon to 3:00 P.M.).
Location of Accident (Include city and state)
Indicate street or intersection, mile marker, or a description (e.g., On Route 83 five miles north of the Smallville intersection with Route 59).
Enter the name of the police department or other authority to which the accident was reported, including any precinct or station number, if available.
If a case or file number has been assigned, be sure to include that number as well. Usually the report number is the number of the vehicle incident report filed by the police after an automobile accident.
Provide the type of violation/citation and identify the driver who received the citation using driver number.
Description of Accident
Explain how the accident occurred.
Use this section to list the policy limits and deductibles for the insured as shown on the declarations page.
Bodily Injury (Per Person)
Used for split limit policies. Enter the Bodily Injury Per Person Limit.
Bodily Injury (Per Accident)
Used for split limit policies. Enter the Bodily Injury Per Accident Limit.
Used for split limit policies. Enter the Property Damage Per Accident limit.
For combined single limit policies, enter the liability limit in this field.
Indicate the limit (if any) provided for Medical Payments.
Other Than Collision (OTC) Deductible. If physical damage coverage other than collision is provided, enter the deductible amount. If there is no deductible, enter ACV (Actual Cash Value) or other basis. If no coverage is provided, enter N/A.
Other Coverage & Deductibles
Describe any additional coverages and deductibles provided on the policy (e.g., No-Fault, Towing, Full Coverage Glass).
Enter the name of any Loss Payee for the auto involved in the loss. If none, enter N/A.
Collision Deductible. If Collision coverage is provided, enter the deductible amount. If no coverage is provided, enter N/A.
Indicate if such a policy is in force by checking the appropriate box. Also list the carrier. Enter the umbrella or excess policy limits. Indicate if limits apply on a "per claim" or "per occurrence" basis. Also show the applicable self insured retention or deductible.
Use this section to describe the insured's vehicle and the driver involved in the loss. Information entered should correlate to the insured's declarations page whenever possible.
Vehicle Number. Indicate the number assigned to the vehicle as it appears on the policy declarations page.
Model year of the vehicle.
Vehicle's manufacturer (e.g., Buick).
Manufacturer's model name (e.g., Regal).
Vehicle's body type (e.g., two-door sedan).
Enter the full Vehicle Identification Number.
Indicate the license plate number.
State of issuance for the license plate.
Owner's Name & Address
Enter the name and address of the owner of the vehicle. If it is the insured, enter "insured."
Enter the vehicle owner's telephone number with the area code.
Business Phone (A/C, No, Ext)
Enter the vehicle owner's business phone number with area code and extension.
Driver's Name & Address
If this is the owner, check the available box. Otherwise, provide the driver's name and address.
Enter the driver's home telephone number with area code.
Enter the driver's business telephone number, including area code and extension.
Relation to Insured
Indicate the relationship between the driver and the insured (e.g., Insured, wife, child).
Date of Birth
Indicate the driver's birth date.
Driver's License Number
Enter the driver's license number.
State of issuance of the driver's license.
Purpose of Use
Enter a short description of the purpose of the trip during which the accident occurred (e.g., trip to store or commuting to work).
Used With Permission?
Indicate if the vehicle was used with the permission of the owner by placing an "X" in the appropriate box. Explain a "no" response in the Remarks section of the form.
Describe any damage to the insured's vehicle (e.g., right front fender crushed).
If known, give an estimate for the cost of repairing the vehicle.
Where Can Vehicle Be Seen?
Indicate where the adjuster can inspect the vehicle. If other than at the insured's address, include the address.
Indicate the time period the vehicle is available for inspection.
Other Insurance On Vehicle
Provide the company name and policy number on any other applicable insurance. Enter "N/A" if none.
Use this section to describe any property other than the insured vehicle (buildings, other vehicles) damaged in relation to this loss. Check the appropriate box to indicate whether or not the damaged property is a vehicle.
Give a brief description of the type of property damaged, such as home or fence. If a vehicle, list the year, make, model and plate number.
Other Veh./Prop. Ins?
Indicate if the damaged property (or vehicle) is insured or not.
Company or Agency Name
Enter the name of the insurance company or agency covering this property (or vehicle).
Enter the policy number for this property (or vehicle).
Owner's Name & Address
Enter the name and address of the owner of the property (or vehicle).
Enter the home phone number, including area code, of the property owner.
Enter the business telephone number, including the area code and extension, of the property owner.
Other Driver's Name & Address
If the property damaged is another vehicle, enter the name and address of the driver of the other vehicle. Check the box if it is the same as the owner's name and address.
Enter the home telephone number of the driver, including area code.
Enter the business telephone number of the driver, including area code and extension.
Describe the extent of the property damaged (e.g., porch pillar broken, right front fender crushed).
If known, give an estimate of the cost of repair.
Where Can Damage Be Seen?
Indicate where the damaged property is located, including address, so that an adjuster can inspect it.
Use this section to collect information on all injured parties.
Name & Address
Enter the name(s) and address(es) of any people injured in the accident.
Enter the home telephone number, including area code of any injured party.
Indicate if the injured party was a pedestrian by an "X" in this box.
Indicate if the injured party was in the insured's vehicle by an "X" in this box.
Indicate if the injured party was in a vehicle other than the insured's by an "X" in this box.
Enter the age of the injured party.
Extent of Injury
Briefly describe the injury to the injured party (e.g., broken left leg).
WITNESSES OR PASSENGERS
Use this section to describe any additional parties involved in or witnessing the accident.
Name & Address
Enter the name(s) and address(es) of any witnesses or uninjured passengers.
Enter the home telephone number, including area code, of any witness or passenger.
Indicate if the witness or passenger was in the insured's vehicle by an "X' in this box.
Indicate if the witness or passenger was in a vehicle other than the insured's by an "X" in this box.
Describe any other witnesses. If they were not in the insured's vehicle or other involved vehicle, include the location from which they witnessed the incident.
List any other additional information that will assist in properly reporting and settling this claim. Include the adjuster's name if known.
Indicate the name of the individual who reported the loss.
Indicate the name of the individual within the agency or company to whom this loss was reported.
Signatures of Producer and Insured
This form should be signed by the producer and the insured.
Note: Important state information is on the second side of this form.
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