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2. County of Lancaster Automobile Incident Form
4. Date and Time of Incident*
   Date and Time of Incident

   Date and Time of Incident
6. Location of Incident*
8. Description of Incident*
10. Type of Loss*

    1. Property
    2. Liability

    1. Auto
    2. Crime

    1. Professional
    2. Other
12. Cause of Loss*
14. Damaged Property Owner / Injured Person # 1
16. First Name*
17. Last Name*
19. Address1*
21. Address2
23. City*
24. State*
25. Zip*
27. Telephone*
28. Sex*

    1. Male

    1. Female
30. Occupation
31. Employer
33. Driver's License Number
34. Expiration Date
36. License Plate
37. Expiration Date
39. Insurance Carrier*
40. Policy Number
42. Describe Damages
44. Upload Pictures
46. Describe Injuries
48. Damaged Property Owner / Injured Person # 2
50. First Name*
51. Last Name*
53. Address1*
55. Address2
57. City*
58. State*
59. Zip*
61. Telephone*
62. Sex*

    1. Male

    1. Female
64. Occupation
65. Employer
67. Driver's License Number
68. Expiration Date
70. License Plate
71. Expiration Date
73. Insurance Carrier*
74. Policy Number
76. Describe Damages
78. Upload Pictures 2
80. Describe Injuries
82. Damaged Property Owner / Injured Person # 3
84. First Name*
85. Last Name*
87. Address1*
89. Address2
91. City*
92. State*
93. Zip*
95. Telephone*
96. Sex*

    1. Male

    1. Female
98. Occupation
99. Employer
101. Driver's License Number
102. Expiration Date
104. License Plate
105. Expiration Date
107. Insurance Carrier*
108. Policy Number
110. Describe Damages
112. Upload Pictures 3
114. Describe Injuries
Leave This Blank:


116. 1. Receive an email copy of this form.
117. Email address

     This field is not part of the form submission.

118. Submit

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