Property Loss Notice

Policy Number
Policy Date From
Date Format: MM slash DD slash YYYY
TO
Policy Date
Date Format: MM slash DD slash YYYY
Producer Name
INSURED INFORMATION
Name
Address
Street Address City ZIP / Postal Code
State
Primary Phone
Alternate Phone
Email Address
CONTACT INFORMATION
If Different from Insured
Name
Address
Street Address City ZIP / Postal Code
State
Primary Phone
Alternate Phone
Email Address
LOSS INFORMATION
Date of Loss
Date Format: MM slash DD slash YYYY
Time of Loss

: HH

MM
Reported by
Location of Occurrence
Police or Fire Dept. to which Reported
Kind of Loss
Describe Other Loss
Probable Amount of Entire Loss
Description of Loss & Damage
Remarks
APPLICABLE IN CALIFORNIA

PRIVACY NOTICE: Your privacy is important to us. To learn more about the categories of personal information we collect through this form, and how we use this information, please visit our privacy policy here.

For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

APPLICABLE IN NEVADA

Pursuant to NRS §686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete, or misleading information concerning a material fact is guilty of a felony.

APPLICABLE IN WASHINGTON

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

APPLICABLE IN ARIZONA

For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Property Loss Notice

TO

INSURED INFORMATION

CONTACT INFORMATION

LOSS INFORMATION

APPLICABLE IN CALIFORNIA

APPLICABLE IN NEVADA

APPLICABLE IN WASHINGTON

APPLICABLE IN ARIZONA