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Correira Insurance Agency, Inc.
 Business Loss Notice 
Business Loss Notice

Contact Information
Your Full Name:
(as listed on policy now)
Your Email Address:
Daytime Telephone Number:
Description of Loss
Time & Date of Accident/Claim:
Time AM PM
Date
Location:

Type of Accident/Claim:

Property
Liability
Automobile
Workers Comp
Other:

Description of Loss:

Name(s) of Injured Parties:
Vehicle Description:
(applicable to Auto Claims Only)
Driver Name:
(applicable to Auto Claims Only)
Any Additional Information Not Requested Above
Please Note: Insurance coverage cannot be bound without a written binder from our office.

123 Broadway Taunton, MA 02780

Phone: 508-822-2999

HOURS:

Mon.- Fri. 8 to 5

Sat. 9 - 12

Remember to make a copy of your auto  registration. If you loose the original you will save $25 for a copy at the registry.

Manage My Policy 

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