The Perimeter Group

Auto Loss Notice

Name on Policy
Your Email Address
Daytime Telephone Number
Time & Date of Accident/Claim		Time: AM PM Date:
Location of Accident
Description of Accident
Were the Police Notified?		Yes No
Were you ticketed?		Yes No
If you received a ticket, what was it for?
Driver Name
Additional Comments
IMPORTANT! I have read and understand the following: By completing and submitting this form you agree that no coverage is bound and no policy is in effect until you are contacted by one of our representatives. All information submitted is held in the strictest confidence and is only gathered for the purposes of providing you an insurance quote. To provide the most accurate quote possible please complete all areas that apply.