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Auto Loss Notice

Automobile 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 of Accident:
Description of Accident:
Police Notified?:	Yes No
Were you ticketed?:	Yes No
If you received a ticket, what was it for?:
Driver Name:

Any Additional Information Not Requested Above


Please Note: Submitting this form via the website does not constitute a "formal" claim. Please contact us or your insurance company to notify of a loss.

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Palomino Insurance Agency

Corporate Office

8889 E. Bell Rd #201
Scottsdale, AZ 85260
Office # 480-483-8000

California Office

Serving Los Angeles, San Diego
& Orange County
26359 Jefferson Ave #D
Murrrieta, CA 92562
Office # 949-300-2050

License Information:

AZ Palomino Agency Department of Insurance License #910284
AZ Mike Palomiono Az Department of Insurance License #704684
CA Individual Approved License #0H39335
CA Broker Corp LIC #OH58343
UT Mike Palomio Individual. #375139