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

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.

Blackwell Insurance Agency
575 Main StreetCorinth ME, 04427
311 Corinna RoadDexter, ME 04930
Phone: Corinth: 207-285-3254   Dexter: 207-924-7377 Fax: Corinth : 207-285-7034  Dexter: 207-924-6696