McMartin, Wasek & Associates, Inc. - Adjustment Services for the Millennium

10370 Citation Drive, Suite 100

Brighton, MI 48116

Phone:  866-937-7009

Fax:     (989) 229-8039

P.O. Box 888364

Grand Rapids, MI 49588

Phone:  866-937-7008

Fax:     (989) 893-0208

Please complete the following form. When finished, print this page for your records.
(Required fields are marked with a *.)
Automobile Loss Notice
Date: *
AGENT: * Address: *
Phone: * City / State: *
Fax: * Zip: *
COMPANY: * Address: *
Adjuster: * City / State: *
Company Phone: * Zip: *
Company Fax: *
Policy Number: * Policy Eff. Date: *
Claim Number: * Policy Exp. Date: *
Date & Time of Loss: *
Previously Reported: * Yes No

 

Insured
First Name: * Insured's Residence Phone:
Last Name: * Insured's Business Phone:
Address: * Person to Contact:
Address: (second line) Where to Contact:
City: * When to Contact:
State:* Contact's Residence Phone: *
Zip: * Contact's Business Phone: *
Fax:

 

Loss

Location of Accident:

Description of Accident:

Authority Contacted & Report Number:

Violations/Citations:

 

Policy Information
Bodily Injury: Property Damage: Single Limit:
Med. Pay: OTC Deductible: Collision Deductible:
Loss Payee:

Other Coverage:

 

Insured Vehicle 
Year / Make / Model: Owner's Name:
Plate Number: Address:
V.I.N.: City / State:
Vehicle Number: Zip:
Phone:
Driver's Name: Residence Phone:
Address: Business Phone:
City / State:
Zip: Estimate Amount:
Relation to Insured: Purpose of Use:
Date of Birth: Used With Permission: Yes No

Other Insurance on Vehicle:


Describe Damage:


Where and When can Vehicle be Seen:

 

Claimant  
Company or Agency Name: Policy Number:
Owner's Name: Business Phone:
Address: Residence Phone:
City / State:
Zip: Estimate Amount:
Other Driver's Name: Residence Phone:
Address: Business Phone:
City / State:
Zip:

Other Vehicle or Property Insurance:


Describe Property:


Describe Damage:


Where and When can Damage be Seen:

 

Injured   

Name and Address:

Phone

Ped.

Ins.
Veh

Other Veh.

Age

Extent of Injury

 

Witnesses or Passengers

Name and Address:

Phone:

Ins. Vehicles:

Other Vehicles:

Other(Specify):

Remarks:
Reported By: Reported To: