Phalanx Industry Corporation

Transportation

Property

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Vehicle Loss Notice
Current Auto Policy Number:
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Email:
Best time to call:
Preferred Contact Method:
Effective Date of Policy Change:
Time and Date of Loss:
Location of Loss:
Description of Loss:
Were the Police notified?	Yes No
Were you ticketed?	Yes No
If Yes, what was the ticket for?
Driver Name: