PROPERTY 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 DESCRIPTION OF LOSS
Time of Loss:
 (please note AM or PM)
Date of Loss:
Location of Property:
Description of Loss:
AUTHORITY NOTIFICATION
Were the Police or Fire Dept. called?
If YES, which authority?
PROPERTY STATUS
Is the property habitable?
If NO, where are you staying:
(address & telephone)
REPORT INFORMATION
Reported by:
Title:
Date:

Additional Comments:

Click "SUBMIT" to send

 

Thank you for recommending our services. To contact us, please click here.


site designed and maintained by

last updated 3-may-03