PROPERTY LOSS NOTICE
You may use the form below to submit a property loss notice directly our agents. An agent from our office will contact you shortly after receiving the request. No claims will be bound until you receive confirmation from our office upon review.
Agent Information:
Agency:
Agent Name:
Phone:
Fax:
Agent E-Mail Address:
Policy Holder Information
Name Insured
(As it appears on the policy):
Address:
Phone #: Work     Home
Email:
Policy #:
Time and Description of Loss
Time & Date of Loss:
Time a.m.
p.m.		     Date
Location of Property:
Description of Loss:
Property Status
Contact Name:
Contact Phone:
Authority Notification
Was the Police or Fire Dept. notified? Yes     No
If Yes, which Authority?
Report Information
Reported by:
Title (if any):
Date:
Additional Comments
Please give any additional comments you feel appropriate for this Loss Notice.
    
Applicant Signature/Print Name
Agent/Producer Signature/Print Name