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?
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)
Are there any injuries to individuals?
Are any third parties potentially responsible for the loss?
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: