Claims Company POLICY NAME Select a policy Business & Commercial General Liability Homeowners Flood Trucking Insurance Trucking Liability Trucking Cargo Trucking Physical Damage Workers Comp Renters Life AUTOMOBILE LOSS NOTICE ACORD 2 | Jaikar Insurance Services | 610 W 6th Street, Corona, CA 92882 | (833) 371 5800 YOUR EMAIL ADDRESS (used to file this claim in our records) Agency AGENCY NAME AGENCY CUSTOMER ID ADDRESS CONTACT PHONE (A/C, No, Ext) FAX (A/C, No) E-MAIL CODE SUBCODE Policy DATE (MM/DD/YYYY) CARRIER NAIC CODE POLICY NUMBER POLICY TYPE INSURED LOCATION CODE DATE OF LOSS AND TIME AM / PM AM PM Insured NAME OF INSURED (First, Middle, Last) DATE OF BIRTH FEIN (if applicable) MARITAL STATUS / CIVIL UNION (if applicable) INSURED'S MAILING ADDRESS PRIMARY PHONE # PRIMARY PHONE TYPE CELL HOME BUS SECONDARY PHONE # SECONDARY PHONE TYPE CELL HOME BUS PRIMARY E-MAIL ADDRESS SECONDARY E-MAIL ADDRESS Contact CONTACT INSURED CONTACT INSURED WHEN TO CONTACT NAME OF CONTACT (First, Middle, Last) CONTACT'S MAILING ADDRESS PRIMARY PHONE # PRIMARY PHONE TYPE CELL HOME BUS SECONDARY PHONE # SECONDARY PHONE TYPE CELL HOME BUS PRIMARY E-MAIL ADDRESS SECONDARY E-MAIL ADDRESS Location of Loss STREET CITY, STATE, ZIP COUNTRY DESCRIBE LOCATION OF LOSS IF NOT AT SPECIFIC STREET ADDRESS POLICE OR FIRE DEPARTMENT CONTACTED REPORT NUMBER Loss DESCRIPTION OF ACCIDENT (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Insured Vehicle VEH # YEAR MAKE MODEL BODY TYPE V.I.N. PLATE NUMBER STATE OWNER'S NAME AND ADDRESS (Check if same as insured) Check if same as insured OWNER'S NAME AND ADDRESS PRIMARY PHONE # PRIMARY PHONE TYPE CELL HOME BUS SECONDARY PHONE # SECONDARY PHONE TYPE CELL HOME BUS PRIMARY E-MAIL ADDRESS SECONDARY E-MAIL ADDRESS DRIVER'S NAME AND ADDRESS (Check if same as owner) Check if same as owner DRIVER'S NAME AND ADDRESS PRIMARY PHONE # PRIMARY PHONE TYPE CELL HOME BUS SECONDARY PHONE # SECONDARY PHONE TYPE CELL HOME BUS PRIMARY E-MAIL ADDRESS SECONDARY E-MAIL ADDRESS RELATION TO INSURED (Employee, family, etc.) DATE OF BIRTH DRIVER'S LICENSE NUMBER STATE PURPOSE OF USE USED WITH PERMISSION? (Y/N) DESCRIBE DAMAGE ESTIMATE AMOUNT WHERE CAN VEHICLE BE SEEN? WHEN CAN VEHICLE BE SEEN? OTHER INSURANCE ON VEHICLE - CARRIER POLICY NUMBER 1. WAS A STANDARD CHILD PASSENGER RESTRAINT SYSTEM (CHILD SEAT) INSTALLED IN THE VEHICLE AT THE TIME OF THE ACCIDENT? Y N 2. WAS THE CHILD PASSENGER RESTRAINT SYSTEM (CHILD SEAT) IN USE BY A CHILD DURING THE TIME OF THE ACCIDENT? Y N 3. DID THE CHILD PASSENGER RESTRAINT SYSTEM (CHILD SEAT) SUSTAIN A LOSS AT THE TIME OF THE ACCIDENT? Y N Other Vehicle / Property Damaged NON-VEHICLE? NON-VEHICLE? OTHER VEH/PROP INS? (Y/N) VEH # YEAR MAKE MODEL BODY TYPE V.I.N. PLATE NUMBER STATE DESCRIBE PROPERTY (Other Than Vehicle) CARRIER OR AGENCY NAME NAIC CODE POLICY NUMBER OWNER'S NAME AND ADDRESS PRIMARY PHONE # PRIMARY PHONE TYPE CELL HOME BUS SECONDARY PHONE # SECONDARY PHONE TYPE CELL HOME BUS PRIMARY E-MAIL ADDRESS SECONDARY E-MAIL ADDRESS DRIVER'S NAME AND ADDRESS (Check if same as owner) Check if same as owner DRIVER'S NAME AND ADDRESS PRIMARY PHONE # PRIMARY PHONE TYPE CELL HOME BUS SECONDARY PHONE # SECONDARY PHONE TYPE CELL HOME BUS PRIMARY E-MAIL ADDRESS SECONDARY E-MAIL ADDRESS DESCRIBE DAMAGE ESTIMATE AMOUNT WHERE CAN DAMAGE BE SEEN? Injured INJURED 1 NAME & ADDRESS PHONE (A/C, No) PED / INS VEH / OTH VEH PED INS VEH OTH VEH AGE EXTENT OF INJURY INJURED 2 NAME & ADDRESS PHONE (A/C, No) PED / INS VEH / OTH VEH PED INS VEH OTH VEH AGE EXTENT OF INJURY Witnesses or Passengers WITNESS / PASSENGER 1 NAME & ADDRESS PHONE (A/C, No) INS VEH / OTH VEH / OTHER (Specify) INS VEH OTH VEH OTHER OTHER (Specify) WITNESS / PASSENGER 2 NAME & ADDRESS PHONE (A/C, No) INS VEH / OTH VEH / OTHER (Specify) INS VEH OTH VEH OTHER OTHER (Specify) Remarks REPORTED BY REPORTED TO REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. SIGNATURE Clear signature Please sign the form before submitting. Attach pictures You may attach up to 25 pictures at the end, before submission. JPG, PNG, GIF, or WEBP. Each file 8 MB or smaller. Choose pictures Select one or more images — maximum 25 0 / 25 pictures attached Submit Claim The claim could not be sent. Please try again or call (833) 371 5800. Thank you. Your filled ACORD loss notice has been emailed and our team will be in touch shortly.