The Frigault Agency, Inc. Protecting all the things you love. Auto, Home, Life, Business, Boat.
 (315) 797-8080
136 Clinton Road (Rt 12b), New Hartford, NY, 13413
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Automobile Loss Notification (Auto Claim)


Please use the form below to notify our agency about a claim towards your automobile policy. You will be contacted shortly by one of our qualified representatives. This does not constitute a claim until confirmed by one of our agents.

Policy Holder Information

You must include your phone number and/or email address so that one of our representatives may contact you.

Full Name of Insured:
Address:
Phone #: Work: Home:
  Cell: Other:
Email Address:

Time and Location of Accident
Time and Location of Accident
Time a.m.
p.m.		     Date
Location of Accident:
(Number, Street, Intersection, city, etc.)
Description of the Accident:

Your Vehicle Information
What car were you driving? Yr.   Make   Model
License Plate #:   State
Is this your car? Yes     No
If No, were you using it with permission? Yes     No     Please explain below:
Was There Damage Done to your vehicle? Yes     No
If Yes, please describe:
Where can the vehicle be seen:
Is the vehicle drivable? Yes     No
   

OTHER Driver Information
Name:
Address:
Phone: Work     Home
Automobile: Yr.   Make   Model
Driver's License #:   State
License Plate #:   State
Insurance Company:
Describe damage to other vehicle:
Where can car be seen?

Injuries, Witnesses, Etc.
If there were any Injuries, please describe:
Please list any Witnesses and/or Passengers: (Please include Name, Address and Phone #)

Police Notification
Were the Police Called? Yes     No
What Authority?
Were You Ticketed? Yes     No
If Yes, what for?

Report Information
Reported by:
Title (if any):
Date:


Additional Comments
Please provide any additional comments you feel appropriate for this Loss Notice.


   

We help you find the right solution by understanding your needs. Give us a call(315) 797-8080
136 Clinton Road (Rt 12b), New Hartford, NY, 13413

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