Auto Loss Notice 
Contact Information
Full Name (as listed on policy)
 *
Phone Number
Email Address
 
Description of Loss
Time & Date of Accident/Claim
 *
AM
PM
Location of Accident:
 *
Description of Accident:
 *
Were the police notified?
Were you ticketed?
If you received a ticket what was it for?
Driver Name
 *
Any additional comments or information that might be helpful
 *
 
By completing this form you are acknowledging your understanding of and agreement with the following terms:
1. Submitting this form via the website does not constitute a "formal" claim. Please contact us or your insurance company to notify of a loss.
2. No coverage of any kind is bound or implied by submitting information via this online form.
3. Information from you and other sources such as your driving claims and insurance histories may be used to calculate an accurate price for your insurance.
4. We will not distribute information to other parties other than for insurance underwriting purposes.
5. We value your privacy. Every precaution has been taken to insure your privacy and security.
6. By submitting this form you agree to release us from any liability should this information be accidentally viewed by others.
Security code:
 *
Do not enter anything in this field:
* indicates a required field
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We currently provide insurance services in: 
  • North Carolina
  • South Carolina
  • Virginia

    Please note: Changes to policies via this website are not effective or binding until you, or any party involved, receive official notification from your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

    First Casualty Insurance Group, Inc.
    190-A Turner Street
    Southern Pines, NC 28387
    1-800-352-3416
    fciginfo@fcignc.com
     
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