Automobile Loss Notice

Please use the form below to notify us of any loss or damage to your automobile(s) insured through this company/agency. 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.

» Required Fields

Automobile Loss Notice


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.



Policy Holder Information



Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.




Time and Location of Accident


A.M. P.M.


Police Notification


Were the Police Called? Yes No
Were you Ticketed? Yes No


Vehicle Information


Damage to Your Vehicle? Yes No

Is This Your Car? Yes No
If No, were you using it with permission? Yes No


Other Driver Information



Report Information



Additional Comments



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



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


Buening-Wilks Insurance Agency
9408 Kenwood Road
Cincinnati, OH 45242-6812
Phone: 513-791-8082 Fax: 513-792-5922