Automobile Incident Report

Please use the form below to submit notice for an automobile related loss. Do not give this Incident Report to the guest. A copy may be obtained by contacting Elena Paules in our claims department at (800) 466-8951.

To facilitate the quickest and most accurate response, please complete all of the fields in the following form. Missing information may delay our ability to fulfill your request.

Thank you for helping Petra Risk Solutions to serve you better!

Incident Information:
 
Today's Date:  
 
Property Name:  
Property Address:  
Property Contact Name:  
E-Mail Address:  
Property Phone Number:  
Date of Occurrence:  
Date Reported:   
   
Insured Vehicle:
Make:  
Model:  
Year:  
VIN Number
(Last Five Digits):		  
   
Driver's Name:  
Phone Number:  
Used With Permission?
   
Describe Damage:  
Where Can Vehicle Be Seen:  
Estimated Amount of Loss:  
   
   
Other Vehicle(s) Involved:
  Driver #1 Driver #2
Driver Name:    
Address:    
Phone Number:    
Make:    
Model:    
Year:    
Auto Insurance:    
Phone Number:    
   
   
Description:
   
   
 
 


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800.466.8951 | Cerritos, CA 90703
 
   
 
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