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OGINO-AIZUMI INSURANCE

Automobile Loss Notice

NO COVERAGE OF ANY KIND IS BOUND BY SUBMITTING INFORMATION VIA THIS ONLINE FORM.

Completion of this form does not constitute an actual claim, but serves to notify your agent of an existing loss or claim.

By completing this form, you are acknowledging your understanding of and agreement with these term

 
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:
Additional Information Will be Requested Upon Receipt of This Notice.
Site Mailing List 

Ogino-Aizumi Insurance Agency
1818 W. Beverly Blvd., Suite 210
Montebello, CA 90640
Phone: (323) 728-7488
Fax: (323)724-5611
Email: paul@oginoaizumi.com

 

 

 

 

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