Submit Auto Loss Claim

Department	University	Address	City	State	Zip
	NC State University	P.O. Box 7521	Raleigh		27695-7521

Please enter the Vehicle License Tag then press Tab on your keyboard.

Fields marked with asterisk ( * ) are mandatory.

License Tag * :

Serial/VIN Number * :

Title * :

Department Phone Number * :

Department * :

State Driver Phone Number * :

Name of State Driver * :

State Licensed * :

Driver License # * :

Date of Accident:

Location of Accident (including City & State) * :

Law Enforcement Agency * :

Report Number * :

Identify the Damaged Property of Others (if Auto, Year, Make, Model, Plate #) * :

Description of Accident:

Owner Name and Address :

Primary Phone:

Alternate Phone:

Same as Owner? :

Yes No

Driver Name and Address (Check if same as owner) :

Primary Phone:

Alternate Phone

Describe Damage Property of Others :

Where can damage be seen? * :

Describe Damage to this Vehicle :

Type	File Name	Date Attached	Action
No Records Found.

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