Auto Loss – Hartland Insurance Agency

As your independent agent, we make it our priority to know the necessary coverage required not only by the state of Michigan but by today’s needs. If you’ve had a recent accident, please fill out our Auto Loss Notice form below.

Fields marked with an * are required

Insured

Name *

Residence Phone *

Business Phone *

Email *

Address *

City *

US States *

Zip *

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Contact

Contact Person

Name *

Where to Contact *

When to Contact *

Residence Phone *

Business Phone *

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Accident

Location of Accident *

City *

US States *

Zip *

Authority Contacted *

Report # *

Violations/Citations *

Description of Accident *

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Insured Vehicle

Year *

Make *

Model *

VIN # *

Plate # *

Owner's Name *

Phone *

Owner's Address *

City *

US States *

Zip *

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Driver

Relation to Insured *

Date of Birth *

Driver's License # *

Purpose of Use *

Used with Permission? *

Describe Damage *

Estimate Amount *

Where can Vehicle be Seen? *

When? *

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Property Damaged

Describe Property Damaged (if auto: year, make, model, plate no.) *

Other Veh./Prop/ Ins.? *

Company/Agency Name

Policy #

Owner's Name *

Business Phone *

Residence Phone: *

Owner's Address *

City *

US States *

Zip *

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Other Drive

Other Driver

Name

Business Phone

Residence Phone

Address

City

US States

Zip

Describe Damage

Estimate Amount

Where Can Damage be Seen?

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Injured

Name

Phone

Age

Address

City

US States

Zip

Name

Phone

Address

City

US States

Zip

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Witness or Passenger

Name

Phone

Age

Address

City

US States

Zip

Name

Phone

Age

Address

City

US States

Zip