Alliance Insurance Agency Services in Metairie and Covington, Louisiana

 

AUTOMOBILE LOSS NOTICE

Please use the form below to notify us of any loss or damage to your automobile(s) insured through Alliance Insurance Agency Services, Inc. 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.

Disclaimer:
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
(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:

 

Address:

 

City:

 

State:

Louisiana

 

Zip Code:

 

Work Phone Number:

 

Home Phone Number:

 

Email

 

Time and Location of Accident

Time:

A.M.

P.M.

 

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?

Vehicle Information

Damage to Your Vehicle?

Yes

No

 

If Yes, describe

 

Where Can Vehicle Be Seen?

Vehicle Description

Vehicle Year:

 

Make:

 

Model:

 

State:

 

Is This Your Vehicle?

Yes

No

 

If No, were you using it with permission?

Yes

No

 

Please Explain:

 

Other Driver Information

Name:

 

Address:

 

City:

 

State:

 

Zip Code:

Work Phone Number:

 

Home Phone Number:

 

Vehicle Make:

 

Vehicle Model:

 

License Plate State:

 

Insurance Company:

 

Describe Damage to Other Vehicle:

 

Where Can Vehicle Be Seen?

 

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):

 

Date:

Additional Comments

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

Please click on the "Submit" button below to send your Loss Notice. One of our representatives will respond to your submission as soon as possible.

 

Alliance Insurance Agency Services, Inc.
Serving the Greater New Orleans Area since 1988

In Metairie
4444 York Street
Suite 100
Metairie, Louisiana  70001
 
Phone: (504) 831-2196
Fax: (504) 837-3389
Map to Metairie office
 

In Covington
201 Holiday Blvd
Suite 410
Covington, Louisiana 70433
 
Phone: (985) 273-3150
Fax:(985) 400-5396
Map to Covington office
 

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