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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.
Enter the security code you see above. Code is NOT case sensitive.
*
Doug Haeussler
Agency Sales Manager
dough@hometeaminsurance.com
6836 Dallas Parkway Ste 203
Plano, Texas 75024
Toll Free:
(866) 310 - 6745
Office:
(972) 665 - 1930
Fax:
(972) 212 - 6451
