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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.
Quick Quote Request 
Feddersen Insurance Agency, Inc.
Mailing Address: 905 Joliet Street, #335, Dyer, IN 46311
For Appointments: 5615 W 95th St., Oak Lawn, IL 60453

Office: (708) 623-1600
Fax: (708) 298-5988
 

© Feddersen Insurance Agency, Inc., 2012

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