Automobile Loss Notice

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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: Insurance coverage cannot be bound without a written binder from our office.

  

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Brier Payne Meade, Topeka – (785) 233-1717
Brier Payne Meade, Kansas City – (913) 402-9576

Get Driving Direction To Our Locations