Back
Felix Insurance Planning
Auto Loss Report
We're sorry to hear you have experienced a loss. Please use the form below to contact us. One of our agents will assist you.
Your Full Name:
Your Email Address:
Telephone Number:
Cell Phone Number:
Date of Loss: (mm/dd/yy)
Were You At Fault?
Yes
No
Unsure
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 You Wish To Provide?
Do not enter anything in this field:
