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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.

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Insurance That Grows With You

Klemme Insurance Services, LLC
3211 W. Wadley #20
Midland, TX 79705

Toll Free: (866) 518-5646
 Phone: (432) 687-5646      fax: (432) 684-4428
 email: bob@klemmeinsurance.com  

READ OUR PRIVACY STATEMENT

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