Property Loss Notice
Please use the form below to notify us of any loss or damage to your property insured through this company/agency.
Please note that this form is for notification purposes only and does not constitute making an actual claim.
Contact your insurance carrier promptly to file an actual claim.

Disclaimer:
I understand that this does not constitute an actual claim, but rather a notification to my agent of an existing loss or claim, and may help to expedite the claim process once I have filed.

 * I have read and agree with the above.
(Box must be checked before request can be sent.)

Policy Holder Information

Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.

Name Insured: *

Address:

City:

Zip Code:

State:

Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont US Virgin Islands Washington Wisconsin West Virginia Wyoming

Work Phone Number:

Home Phone Number:

Email: *

Time and Description of Loss

Time:

    A.M.   P.M.

Date:

Location of Property:

Description of Loss:

Authority Notification

Where the Police or Fire Department called?

 Yes   No

If yes, which Authority?

Property Status

Is the property habitable?

 Yes No

If No, where are you staying: (Address and Telephone)

Property Information

Reported by:

Title (if any):

Date:

Additional Comments

Please give any additional comments you feel appropriate for this Loss Notice.

* Indicates a required field