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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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Gordon Insurance Associates, Inc.
8251 West Thunderbird Road, Ste 160
Peoria, Arizona 85381
Office: (623) 486-6815
Fax:     (888) 870-9690
Email: info@giasite.com

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