Skip to the content
Call:
(571) 489-6600
Google Maps Logo (opens in new tab)
Yelp Logo (opens in new tab)
Facebook Logo (opens in new tab)
LinkedIn Logo (opens in new tab)
OSHAlogs Login
(opens in new tab)
Client Portal
(opens in new tab)
Get Quote
(opens in new tab)
Home Page (opens in new tab)
Services
Auto, Home, and Personal Insurance
Auto Insurance
Homeowners Insurance
Renters Insurance
Motorcycle Insurance
Boat & Marine Insurance
- View All Personal
Contractors Insurance
Small Contractors Insurance (1-10 Employees)
Middle Market Contractors Insurance
Surety Bonds
Business Insurance
Life Insurance
Individual Life Insurance
Key Person / Employee Insurance
- View All Life
Group Benefits
OSHA Logs
About
Insurance Companies
Insurance Blog
Careers
Support
Online Billing & Payments
File A Claim
Report a Claim Other than WC
Report a WC Claim
Online Claims Filing
Auto ID Card Request
Certificate of Insurance Request
Policy Change Request
Request A Coverage Review
Insurance Resources
Contact
Fairfax Office
Secure Contact Form
Refer a Friend
Home
>
Loss Notice Form
Call Us Today
(571) 489-6600
Loss Notice Form
Insured
Company Name:
Reported By:
Daytime Phone:
Email Address:
Loss
Location
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Time
:
Hours
Minutes
AM
PM
AM/PM
Date
MM slash DD slash YYYY
Report #
What Happened?
Injured (attach additional sheet if necessary)
Name
First
Last
Daytime Phone
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Transported to Hospital?
Yes
No
Fatality?
Yes
No
Nature of Injury (if known)
Property Damaged Non-Auto (attach additional sheet if necessary)
Owner
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Daytime Phone
Approx. Value: $
Describe Damage
Insured Vehicle
Year
Make/Model
VIN
Owner
Daytime Phone
Driver
Daytime Phone
DOB
MM slash DD slash YYYY
License #
State
Describe Damage
Other Vehicle
Year
Make/Model
Insured By:
VIN
Policy #
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Driver
Daytime Phone
Describe Damage
Comments/Witness Info (name, phone #, details, if available)
Δ
Erie Insurance J.D. Power Award for Home Insurance Claims
Erie Insurance is #1 in Customer Satisfaction with the Home Insurance Claims Experience
Disclaimer: For J.D. Power 2023 award information, visit jdpower.com/awards
September is Life Insurance Awareness Month.
It’s the perfect time to remind ourselves to plan ahead for the ones we love.
Get Started
Erie Insurance - One of America’s Best Insurance Companies
Erie Insurance has been named to the Forbes list of America’s Best Insurance Companies for 2022.
Get A Quote