AUTOMOBILE LOSS NOTICE

Please use the form below to notify us of any loss or damage to your automobile(s) insured through Rekerdres Insurance Agency. Please note that this form is for notification purposes 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 disclaimer

POLICY HOLDER INFORMATION
Name Insured:
Email:
Address:
City:
State:
Zip:
Work Phone:
Home Phone:
TIME AND LOCATION OF ACCIDENT
Time of Loss:
 (please note AM or PM)
Date of Loss:
Location of Accident:
(Number, Street, Intersection, etc)
Description of Accident:
POLICE NOTIFICATION
Were the police called?
What authority?
Were you ticketed?
If YES, what for?
YOUR VEHICLE INFORMATION
Damage to your vehicle?
If YES, please describe:
Where can car be seen?
What car were you driving?
 Year:
Make:
Model:
License Plate #:
State:
Is this your car?

If NO, were you using it with permission?

 

Please explain below:

CONTINUE TO PAGE 2 OF 2

 



site designed and maintained by

last updated 3-may-03