Lappan Agency Inc.
Automobile Loss Notice
Your Full Name as listed on your Policy:
Please enter your email address:
Daytime Telephone Number:
Time & Date of Accident/Claim:
Time:
Select
AM
PM
Date:
Location of Accident:
Description of Accident:
Police Notified?
Select
Yes
No
Were You Ticketed?
Select
Yes
No
If you received a ticket, what was it for?: