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 Auto Loss Notice 
Automobile Loss Notice

Contact Information
Your Full Name:
(as listed on policy now)
Your Email Address:
Daytime Telephone Number:
Description of Loss
Time & Date of Accident/Claim:
Time AM PM
Date
Location of Accident:


Description of Accident:
Police Notified?:
Yes No
Were you ticketed?:

Yes No

If you received a ticket, what was it for?:
Driver Name:
Any Additional Information Not Requested Above
Please Note: Submitting this form via the website does not constitute a "formal" claim. Please contact us or your insurance company to notify of a loss.
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Agency NPN 17983521
Agency License 107813529           

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Insurance Services for Risk and Assets Management
1043 S York Rd LL3, Bensenville IL 60106
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