Agent Name

Date and Time of Loss

Date Form Completed

Insured Name

Address

City

State/Zip

Phone (Home/Cell)

Phone (Work)

Contact Person

Best Time to Contact

Policy Number

Location of Loss

Reported to Police or Fire Dept.

Yes     No

If yes, what agency responded

Type of Loss

Fire   Lightning   Wind   Hail   Water
Theft   Smoke   Vandalism   Other

Describe the loss:

Please provide specific details.

Mortgagee on property where loss occurred

Yes   No

Policy Deductible

Other insurance covering this property?

Yes   No

Remarks:
Insert any additional information that would help us understand your claim.

Reported by:

Reported to:

Your Phone Number

Relation to Insured:

Disclaimer: This claim will be reviewed and contact will be made as soon as possible on the next regular business day following receipt of this notice. We may not receive this promptly if the report is being completed after office hours or on weekends. This reporting capability is solely for the convenience of filing a claim after hours or when it is not feasible to contact your agent during normal business hours.

Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or another person, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, is subject to criminal prosecution and civil penalties.