Countries and Languages
| Countries | Languages |
|---|---|
| USA | English |
Extracted Fields
Identification
| Field | Description |
|---|---|
| Date | The date on which the form is completed |
| Agency Name | The full name of the producer or agency |
| Agency Address | The address of the producer or agency |
| Contact Name | The name of the primary contact person at the producer’s establishment |
| Phone | The phone number of the primary contact person at the producer’s establishment |
| Fax | The fax number of the producer or agency |
| The e-mail address of the primary contact person at the producer’s establishment | |
| Code | The identification code assigned to the producer (for example, agency or brokerage firm) by the insurer |
| Subcode | The identification code assigned by the insurer to the sub-producer (for example, natural person) within a producer’s office (for example, agency or brokerage) |
| Agency Customer ID | The identification number of the customer assigned by the producer (for example, agency or brokerage) |
| Insured Location Code | The code or identifier associated with the insured location for an insurance policy |
| Date of Loss and Time | |
| Date | The date on which the loss occurred |
| Time | The approximate time at which the loss occurred |
| AM | Indicates that the time specified is AM |
| PM | Indicates that the time specified is PM |
| Carrier | |
| Carrier Name | The insurer’s full legal company name(s) as per the file copy of the policy |
| Carrier Address | The address of the company |
| NAIC Code | The identification code assigned to the insurer by the NAIC |
| Policy Number | The identifier assigned by the insurer to the policy or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured person’s license or contract number is specified instead |
| Policy Type | The type of policy issued to the insured person (for example, personal auto, truckers, garage liability, commercial property, and builder’s risk) |
Insured
| Field | Description |
|---|---|
| Name of Insured | The insured person (natural or legal) covered by the insurance policy |
| Date of Birth | The date of birth of the insured person |
| FEIN | The tax identifier of the named insured person |
| Marital Status or Civil Union | The insured person’s marital status. Possible values: S - Single, M - Married, D - Divorced, P - Separated, W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other |
| Phone 1 | |
| Phone 1 | The primary phone number of the insured person |
| Phone Type | |
| Home | Indicates that the primary phone number is for a home phone |
| Business | Indicates that the primary phone number is for a business phone |
| Cell | Indicates that the primary phone number is for a cell phone |
| Phone 2 | |
| Phone 2 | The secondary phone number of the insured person |
| Phone Type | |
| Home | Indicates that the secondary phone number is for a home phone |
| Business | Indicates that the secondary phone number is for a business phone |
| Cell | Indicates that the secondary phone number is for a cell phone |
| Phone 3 | |
| Phone 3 | The third phone number of the insured person |
| Phone Type | |
| Home | Indicates that the third phone number is for a home phone |
| Business | Indicates that the third phone number is for a business phone |
| Cell | Indicates that the third phone number is for a cell phone |
| Mailing Address | The mailing address of the insured person |
| Primary E-mail | The primary e-mail address of the insured person |
| Secondary E-mail | The secondary e-mail address of the insured person |
Contact
| Field | Description |
|---|---|
| Contact Insured | Indicates whether the individual to be contacted is the same as the insured person |
| Name of Contact | The full name (first, middle, last) of the individual to be contacted as a representative of the insured person on all subsequent business relating to this incident |
| Phone 1 | |
| Phone 1 | The primary phone number of the representative of the insured person |
| Phone Type | |
| Home | Indicates that the primary phone number is for a home phone |
| Business | Indicates that the primary phone number is for a business phone |
| Cell | Indicates that the primary phone number is for a cell phone |
| Phone 2 | |
| Phone 2 | The secondary phone number of the representative of the insured person |
| Phone Type | |
| Home | Indicates that the secondary phone number is for a home phone |
| Business | Indicates that the secondary phone number is for a business phone |
| Cell | Indicates that the secondary phone number is for a cell phone |
| Phone 3 | |
| Phone 3 | The third phone number of the representative of the insured person |
| Phone Type | |
| Home | Indicates that the third phone number is for a home phone |
| Business | Indicates that the third phone number is for a business phone |
| Cell | Indicates that the third phone number is for a cell phone |
| Mailing Address | The mailing address of the representative of the insured person |
| Primary E-mail | The primary e-mail address of the representative of the insured person |
| Secondary E-mail | The secondary e-mail address of the representative of the insured person |
Loss
| Field | Description |
|---|---|
| Location of Loss | |
| Street | The physical street address of the loss location |
| City State ZIP | The city, state or province and postal code of the loss location |
| Country | The country of the loss location |
| Address | The address (including street, city, state or province, postal code, and country) of the loss location |
| Description of Location of Loss | The description of the location of loss if not at a specific street address |
| Description of Accident | An explanation of how the loss occurred |
| Police or Fire Department Contacted | The name of the municipal, country or other police department, fire department or other authority to which the accident was reported, including any precinct or station number, if available |
| Report Number | The report number assigned by the authority contacted |
Insured Vehicle
| Field | Description |
|---|---|
| Vehicle | |
| Vehicle Number | The producer-assigned vehicle number |
| Year | The model year of the vehicle |
| Make | The manufacturer of the vehicle |
| Model | The manufacturer’s model name for the vehicle |
| Body Type | The body type of the vehicle |
| VIN | The car’s vehicle identification number |
| Plate Number | The license plate number |
| State | The state or province in which the vehicle is registered |
| Owner | |
| Same as Insured | Indicates whether the owner of the insured vehicle is the same as the named insured person |
| Owner’s Name | The full name of the person (natural or legal) that is the owner of the vehicle or property |
| Owner’s Address | The address of the owner |
| Phone 1 | |
| Phone 1 | The primary phone number of the owner of the vehicle or property |
| Phone Type | |
| Home | Indicates that the primary phone number is for a home phone |
| Business | Indicates that the primary phone number is for a business phone |
| Cell | Indicates that the primary phone number is for a cell phone |
| Phone 2 | |
| Phone 2 | The secondary phone number of the owner of the vehicle or property |
| Phone Type | |
| Home | Indicates that the secondary phone number is for a home phone |
| Business | Indicates that the secondary phone number is for a business phone |
| Cell | Indicates that the secondary phone number is for a cell phone |
| Primary E-mail | The primary e-mail address of the owner of the vehicle or property |
| Secondary E-mail | The secondary e-mail address of the owner of the vehicle or property |
| Driver | |
| Same as Owner | Indicates whether the owner was the driver of the insured vehicle |
| Driver’s Name | The name of the driver |
| Driver’s Address | The address of the driver |
| Phone 1 | |
| Phone 1 | The primary phone number of the driver |
| Phone Type | |
| Home | Indicates that the primary phone number is for a home phone |
| Business | Indicates that the primary phone number is for a business phone |
| Cell | Indicates that the primary phone number is for a cell phone |
| Phone 2 | |
| Phone 2 | The secondary phone number of the driver |
| Phone Type | |
| Home | Indicates that the secondary phone number is for a home phone |
| Business | Indicates that the secondary phone number is for a business phone |
| Cell | Indicates that the secondary phone number is for a cell phone |
| Primary E-mail | The primary e-mail address of the driver |
| Secondary E-mail | The secondary e-mail address of the driver |
| Relationship to Insured | The relationship of the driver to the named insured person |
| Date of Birth | The birth date of the driver |
| Driver’s License Number | The driver’s license number |
| State | The state in which the driver is licensed |
| Purpose of Use | A short description of the purpose of the trip during which the accident occurred (e.g., trip to store or commuting to work) |
| User with Permission | |
| Yes | Indicates whether the driver had permission to use the vehicle |
| No | Indicates whether the driver had permission to use the vehicle |
| Describe Damage | Description of any damage to the vehicle or property |
| Child Seat Installed | Indicates whether a standard child passenger restraint system (child seat) was installed in the vehicle at the time of the accident. Possible values: Yes, No |
| Child Seat In Use | Indicates whether the child passenger restraint system (child seat) was in use by a child during the time of the accident. Possible values: Yes, No |
| Did Child Seat Sustain a Loss | Indicates whether the child passenger restraint system (child seat) sustained a loss at the time of the accident. Possible values: Yes, No |
| Estimate Amount | An estimate for the cost of repairing the vehicle or property |
| Where Can Vehicle Be Seen | The address where the adjuster can inspect the vehicle or property |
| When Can Vehicle Be Seen | The time period during which the vehicle or property is available for inspection |
| Carrier of Other Insurance | The insurer’s name on any other applicable insurance |
| Policy Number | The policy number of any other applicable insurance |
Other Vehicle or Property Damaged
| Field | Description |
|---|---|
| Vehicle | Indicates whether the damage was inflicted on a vehicle |
| Non-Vehicle | Indicates whether the damage was inflicted on a vehicle |
| Damaged Vehicle | |
| Vehicle Number | The producer-assigned vehicle number |
| Year | The model year of the vehicle |
| Make | The manufacturer of the vehicle |
| Model | The manufacturer’s model name for the vehicle |
| Body Type | The body type of the vehicle |
| VIN | The car’s vehicle identification number (VIN) |
| Plate Number | The license plate number |
| State | The state or province in which the vehicle is registered |
| Property Description | A brief description of the type of property damaged, such as home or fence |
| Other Vehicle or Property Insured | |
| Yes | Indicates whether the damaged property or vehicle was insured or not |
| No | Indicates whether the damaged property or vehicle was insured or not |
| Carrier or Agency Name | The insurer’s name on any other applicable insurance |
| NAIC Code | The NAIC code of the insurance company that issued the policy |
| Policy Number | The policy number of any other applicable insurance |
| Owner | |
| Owner’s Name | The full name of the person (natural or legal) that is the owner of the vehicle or property |
| Owner’s Address | The address of the owner of the vehicle or property |
| Phone 1 | |
| Phone 1 | The primary phone number of the owner of the vehicle or property |
| Phone Type | |
| Home | Indicates that the primary phone number is for a home phone |
| Business | Indicates that the primary phone number is for a business phone |
| Cell | Indicates that the primary phone number is for a cell phone |
| Phone 2 | |
| Phone 2 | The secondary phone number of the owner of the vehicle or property |
| Phone Type | |
| Home | Indicates that the secondary phone number is for a home phone |
| Business | Indicates that the secondary phone number is for a business phone |
| Cell | Indicates that the secondary phone number is for a cell phone |
| Primary E-mail | The primary e-mail address of the owner of the vehicle or property |
| Secondary E-mail | The secondary e-mail address of the owner of the vehicle or property |
| Driver | |
| Same as Owner | Indicates whether the owner was the driver of the insured vehicle |
| Driver’s Name | The name of the driver |
| Driver’s Address | The address of the driver |
| Phone 1 | |
| Phone 1 | The primary phone number of the driver |
| Phone Type | |
| Home | Indicates that the primary phone number is for a home phone |
| Business | Indicates that the primary phone number is for a business phone |
| Cell | Indicates that the primary phone number is for a cell phone |
| Phone 2 | |
| Phone 2 | The secondary phone number of the driver |
| Phone Type | |
| Home | Indicates that the secondary phone number is for a home phone |
| Business | Indicates that the secondary phone number is for a business phone |
| Cell | Indicates that the secondary phone number is for a cell phone |
| Primary E-mail | The primary e-mail address of the driver |
| Secondary E-mail | The secondary e-mail address of the driver |
| Describe Damage | Description of any damage to the vehicle or property |
| Estimate Amount | An estimate for the cost of repairing the vehicle or property |
| Where Can Damage Be Seen | The location where the adjuster can inspect the vehicle or property |
Injured (Repeating Group)
| Field | Description |
|---|---|
| Name | The name of a person that was injured in the incident or accident |
| Address | The address of a person that was injured in the incident or accident |
| Phone | The primary phone number of the injured party |
| Pedestrian | Indicates whether the injured party was a pedestrian |
| Insured Vehicle | Indicates whether the injured party was in the vehicle of the insured person |
| Other Vehicle | Indicates whether the injured party was in a vehicle other than the vehicle of the insured person |
| Age | The age of the injured party at the time of the incident |
| Extent of Injury | A brief description of the injury sustained by the injured party |
Witnesses or Passengers (Repeating Group)
| Field | Description |
|---|---|
| Name | The name of a person that was a witness to the incident or an uninjured passenger |
| Address | The address of a person that was a witness to the incident |
| Phone | The primary phone number of a person that was a witness to the incident |
| Insured Vehicle | Indicates whether the witness was in the vehicle of the insured person at the time of the incident |
| Other Vehicle | Indicates whether the witness was in a vehicle other than that of the insured person at the time of the incident |
| Other | Additional information related to the incident. |
Reported By
| Field | Description |
|---|---|
| Reported by | The name of the individual that reported the loss |
Reported To
| Field | Description |
|---|---|
| Reported to | The name of the individual within the agency or company to whom this loss was reported |
Remarks
| Field | Description |
|---|---|
| Remarks | Other general remarks regarding the automobile loss notice |
Key Fields
- Date
- Agency Name
- Agency Customer ID
- Name of Insured
- Plate Number
Validation Rules
| Rule | Description |
|---|---|
| Copy Owner/Driver Details if Same as Insured/Owner | If Insured Vehicle/Owner/Same as Insured is checked, and Owner’s Name or Owner’s Address are empty, the rule copies values of the Insured/Name of Insured and Insured/Mailing address fields to the corresponding Owner’s Name and Owner’s Address fields. If Insured Vehicle/Driver/Same as Owner is checked, and Driver’s Name or Driver’s Address are empty, the rule copies values of the Owner’s Name and Owner’s address fields to the corresponding Driver’s Name and Driver’s Address fields |
| Copy DamagedVehicle DriverDetails if Same as Owner | If Other Vehicle or Property Damaged/Driver/Same as Owner is checked, and Driver’s Name or Driver’s Address are empty, the rule copies the values of the Owner’s Name and Owner’s address fields to the corresponding Driver’s Name and Driver’s Address fields |
| User With Permission Yes Checkmark, User With Permission No Checkmark, Other Vehicle or Property Insured Yes Checkmark, Other Vehicle or Property Insured No Checkmark | Where applicable, converts all true-or-false fields (for example, checkmarks, and yes or no fields) to Y/N format |