Paul Bernieri Agency - Auto Loss Notice

Only $39

Sponsored By: American Safety Inc. #028

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.