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Automobile Loss Notice

Please use the form below to notify us of any loss or damage to your automobile(s) insured through this company/agency. Please note that this form is for notification purposes only and does not constitute making an actual claim. One of our representatives will contact you shortly after receiving this notification.

Please Note: It is highly recommended that you read and/or print this form in its entirety and gather materials or information for your responses prior to filling out the form online. Any information you input will be lost if you close your browser or navigate to another page or website prior to submitting your information by pressing the "Submit" button at the bottom of this form.

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Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.

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Disclaimer
I understand that this does not constitute an actual claim, but is rather a notification to my agent of an existing loss or claim, and may help expedite the claim process once I have filed.

 I have read and agree with the above disclaimer.
  (Box must be checked before request can be sent)

Policy Holder Information
Please be sure to supply your phone number and email address
so that we may contact you after receiving this notification.
Name Insured:
Address:
Phone #: Work     Home
Email:
Policy Number:

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

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

Your Vehicle Information
Damage to your vehicle? Yes     No
If Yes, describe:
Where can car be seen:
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:

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 #)

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


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

Please click on the "Submit Form" button to send your request.
One of our representatives will respond to your submission as soon as possible.

   

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  Anco Insurance
1111 Briarcrest Drive
Bryan, TX, 77802

979-776-2626
800-749-1733