North Country Estates, Inc.
5427 Shady Ave., Lowville,  NY  13367    
Phone: (315) 376-7131                                  E-mail:
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Automobile Loss Notification

Please use the form below to notify our agency about a claim towards your automobile policy. You will contacted shortly by one of our qualified representatives. This does not constitute a claim until confirmed by one of our agents.

Policy Holder Information

You must include your phone number and/or email address so that one of our representatives may contact you.


Full Name of Insured:
Phone #: Work: Home:
Email Address:

Time and Location of Accident
Time & Date of Accident
Time a.m.
Location of Accident:
(Number, Street, Intersection, city, etc.)
Description of the Accident:

Your Vehicle Information
What car were you driving? Yr.   Make   Model >
License Plate #:   State
Is this your car? Yes     No
If No, were you using it with permission? Yes     No     Please explain below:
Was There Damage Done to your vehicle? Yes     No
If Yes, please describe:
Where can the vehicle be seen:

OTHER Driver Information
Phone: Work     Home
Automobile: Yr.   Make   Model
Driver's License #:   State
License Plate #:   State
Insurance Company:
Describe damage to other vehicle:
Where can car be seen?

Injuries, Witnesses, Etc.
If there were any Injuries, please describe:
Please list any Witnesses and/or Passengers: (Please include Name, Address and Phone #)

Police Notification
Were the Police Called? Yes     No
What Authority?
Were You Ticketed? Yes     No
If Yes, what for?

Report Information
Reported by:
Title (if any):

Additional Comments
Please provide any additional comments you feel appropriate for this Loss Notice.



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