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First Notice of Loss Form - Auto

As of 9/18/2021
* denotes required information

  Policy Number:        
*Loss Reported By:   

Insured Contact Information

*Contact Name: E-Mail Address:
Address: *Primary Phone:
City: Secondary Phone:

Basic Loss Information

*When did the accident happen?
MM/DD/YYYY format
Time of Accident: :
Where did the accident happen?
What Happened? 
(Select all that apply) 
Collision with another vehicle
Collision - All other
Weather Related
Other - Not listed above
*Description of accident/incident:
250 characters max
Was a Police Report Filed?  
Report Number:
Responding Police department:

Vehicle Information

What vehicles were involved in the accident?
Driver NameYearMakeModelVIN #Safely Drivable Auto?

Contact Information

Who was involved in the accident or witnessed the accident?
NamePhone #AddressCityStateZipRole


Was anyone injured?
NamePhone #Describe Injuries
By clicking this check box, you agree to receive an email confirmation of this claim form from Republic Group.
If you experience any issues using this form, or if you wish to speak to a Republic Claim Representative,
call 800-344-2275.