Blue Ridge Insurance & Title Agency
  Phone: 540.955.1178 (540)955-1178   Email Us
Blue Ridge Insurance & Title Agency

Independent Insurance Agent
Independent Insurance Agent

Trusted Choice

Blue Ridge Insurance & Title Agency

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.

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:
Phone #: Work     Home

Time and Location of Accident
Time & Date of Loss
 Time         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
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):

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

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


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This Auto Loss Notice Form Copyright © 1999 - by ENHANCED Web Services


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Blue Ridge Insurance & Title Agency Blue Ridge Insurance & Title Agency
Blue Ridge Insurance & Title Agency
110 S. Church Street
Berryville, Virginia 22611
Blue Ridge Insurance & Title Agency
Blue Ridge Insurance & Title Agency

Important Note:   This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states.
For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.
Blue Ridge Insurance & Title Agency
Blue Ridge Insurance & Title Agency
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