This form is used to initiate a claim with the insurance company. Please provide as much detail as possible to facilitate a prompt investigation and resolution.
Policyholder/Insured Name:
Policy Number:
Contact Person for Claim:
Relationship to Policyholder:
Daytime Phone Number:
Evening Phone Number:
Email Address:
Mailing Address:
Street Address
City
State/Province
Postal/Zip Code
Date of Loss:
Time of Loss:
Location of Loss (Full Address):
Street Address
City
State/Province
Postal/Zip Code
Type of Claim (Check all that apply)
Auto/Vehicle Accident
Property Damage (Home/Commercial Building)
Theft/Burglary
Personal Injury/Liability
Equipment/Machinery Breakdown
Other:
Has the incident been reported to authorities?
If Yes, please provide:
Authority Name (e.g., Police, Fire Dept.):
Report/Incident Number:
Name of Officer/Investigator:
How did the loss occur? (Provide a detailed, chronological account of events.
What is the current status of the damaged/lost property? (e.g., secured, towed, being repaired, etc.)
Description of Damaged Item(s): (e.g., House roof, Sedan car, Forklift, Inventory)
Nature/Extent of Damage: (e.g., Total fire loss, Rear-end collision, Water pipe burst)
Are there immediate steps needed to prevent further damage? (e.g., board up windows, emergency repairs)
If Yes, please describe:
Are there any injuries to individuals?
If Yes, please list names, general description of injuries, and whether they required medical attention:
Name of Injury | Description of Injury | Medical Attention | ||
|---|---|---|---|---|
A | B | C | ||
1 | ||||
2 | ||||
3 | ||||
4 | ||||
5 |
Are any third parties potentially responsible for the loss?
If Yes, please provide their details (See IV).
(For vehicle accidents, liability claims, or losses involving outside parties)
Field | Third Party 1 | Third Party 2 | ||
|---|---|---|---|---|
A | B | C | ||
1 | Name | |||
2 | Address | |||
3 | Phone Number | |||
4 | Relationship to Loss | |||
5 | Vehicle/Property Description | |||
6 | Third Party Insurance Company | |||
7 | Third Party Policy Number |
I certify that the information provided in this Notice of Loss is true and accurate to the best of my knowledge and belief. I understand that the information contained herein is the basis for initiating the claim and is subject to investigation by the insurance company.
Signature:
To configure an element, select it on the form.