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Rutherford One Insurance Services LLC - Specializing in Homeowners, Dwelling, Property, Condo, Apartment and Renters Insurance for California
Latest News!

Rutherford One Insurance Services LLC is now a CARFAX authorized representative and now offers special pricing for a Full History CARFAX Report. Providing this service is just another layer of protection we can provide to our clients when making a decision to purchase a motor vehicle. Contact us for more details.

CARFAX

Now partnering with Hagerty "The Classic and Collector Car insurance Specialist"  

Hagerty Collector Car Insurance

Now licensed in Arizona AZ License #: 1013921



Now licensed in Nevada NV License #: 857071



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Automobile Loss Form...

Automobile Loss Notice
Please use the form below to notify us of any loss or damage to your automobile(s) insured through this Rutherford One Insurance Services LLC. Please note that this form is for notification purposes only and does not constitute making an actual claim. One of our representatives will contact you shortly after receiving this notification.

Disclaimer:
I understand that this does not constitute an actual claim, but is rather a notification to my agent of an existing loss or claim, and may help expedite the claim process once I have filed.
    I have read and agree with the above
(Box must be checked before request can be sent)

Policy Holder Information
Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.
Name Insured:  
Address:  
City:  
State:  
Zip Code:  
Work Phone:  
Home Phone:  
Email:  

Time and Location of Accident
Time:  
    A.M.   P.M.  
Date:  
Location of Accident:
(Number, Street, Intersection, etc.)
 
Description of Accident:  

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

Vehicle Information
Damage to Your Vehicle?   Yes   No  
If Yes, describe:  
Where Can Vehicle Be Seen?  
Vehicle Year:  
Make:  
Model:  
License Plate Number:  
State:  
Is This Your Car?   Yes   No  
If No, were you using it with permission?   Yes   No  
Please Explain:  

Other Driver Information
Name:  
Address:  
Work Phone:  
Home Phone:  
Vehicle Year:  
Make:  
Model:  
Driver's License Number:  
Driver's License State:  
License Plate Number:  
Licens Plate State:  
Insurance Company:  
Describe Damage to Other Vehicle:  
Where Can Vehicle Be Seen?  
If There Were Any Injuries, Please Describe:  
Please List Any Witnesses and/or Passengers:
(Please include name, address, and phone)
 

Report Information
Reported By:  
Title (if any):  
Date:  

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

Please click on the "Submit" button to send your Loss Notice. One of our representatives will respond to your submission as soon as possible.

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Contact Us Today
at 916-962-9909 or
Email
us for further information.

Rutherford One Insurance Services LLC
is licensed by the California Department
of Insurance, Lic# 0N06291.

Rutherford One Insurance Services LLC accepts VISA, MasterCard, Discover and AMEX credit cards
Rutherford One Insurance Services LLC accepts
these forms of payment for your convenience


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