B. R. & Y Insurance Agency, Inc. - Auto Loss Notice

Skip to main content

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.

Manage Your Policy

Change of Address

Certificate of Insurance

Visit our online customer service center here.

Privacy Policy | Copyright Information | Notices

© B. R. & Y Insurance Agency, Inc., 2007-2011 Powered By: Insurance Web Designs