KNI Automobile First Notice of Loss

Today's Date

KNIC Policy Number

Date of loss

Name of Person Reporting Claim

Reporting Person’s Relationship to Insured

Phone Number

INSURED:

Name of Insured

Primary Phone

Street

City

State

Zip

Secondary Phone

Email Address

Contact Name if Different

Phone Number of Contact

LOSS:

Location - Street

Location - City

Location - State

Responding Police Dept

Report #

Description of Accident

# of Vehicles Involved

# of Injuries in Insured Vehicle

# of Injuries in Other Vehicle(s)

# Transported to Hospital

Photos Taken By

INSURED VEHICLE:

Year

Make

Model

VIN

Describe Damage

Photos Taken?

If Vehicle Towed:

Location Name, City

Location Contact Name

Location Phone Number

Driver's Name

Same as Insured's?

Driver's Address

Same as Insured's?

Driver's Phone

Same as Insured's?

Driver's Driver's License

Name & Phone # of Owner, If Different from Insured

OTHER VEHICLE:

Year

Make

Model

VIN

Describe Damage

Photos Taken?

If Vehicle Towed:

Location Name, City

Location Contact Name

Location Phone Number

Driver's Name

Driver's Address

Driver's Phone

Driver's Driver's License

Name & Phone # of Owner, If Different from Insured

INJURIES:

Full Name and Address 1

In Insured's Vehicle

In Other Vehicle

Phone Number

OTHER REMARKS:

(Other Injuries, Passengers, Witnesses, Other Vehicles, or Other Details)

Upload Photos or PDF's?

Note: .jpg, .jpeg, .png. or .pdf , max size 5MB each

"Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime."