McSweeney & Ricci Insurance Agency. Inc.

Auto Loss Report Form

Please complete the following form and click the "Send Report" button to submit an accident report.

***Note: This form does not replace contacting your agent. This report is simply a vehicle to inform your agent of a loss, and allow the agency to prepare accordingly. A claims representative will attempt to contact you immediately upon receipt of this report.

Insured Information

Insured Name
Insured Address

City		State		Zip
County

Insured Resident Phone

Insured Business Phone

E-Mail

Contact Information

Contact Name(if different)
Where to Contact
When to Contact

Contact Resident Phone
(if different)

Contact Business Phone
(if different)

Loss Information

Location of accident
Description of accident
Authority information (reports filed, violations cited)
Date of Loss

Insured Vehicle Description

Vehicle #1 (Year, Make & Model)
Plate Number

Owner Information (if different from insured)

Owner Name
Owner address

Driver Information (if different from insured)

Driver Name
Driver Address
License Number

Other Vehicle & Driver Information

Other Vehicle Year, Make & Model
Other Vehicle Plate Number
Other Driver Name
Other Driver Address (incl. city, state, zip)
Other Driver License Number