Property Loss Notice

Date / /
Policy Number -
Policy Effective Date / /   Policy Expiration Date / /
Date Of Loss / /              Time Of Loss : AM PM

Producer
Name 1  
Name 2  
Address 1
Address 2
City         State Zip
Telephone Number - -

Insured
Name 1  
Name 2  
Address 1
Address 2
City         State Zip
Residence Phone Number  - -
Business Phone Number    - -

Contact
Name 1  
Name 2  
Address 1
Address 2
City         State Zip
Residence Phone Number  - -
Business Phone Number    - -
Where To Contact
When To Contact 

Location Of Loss
Address 1
Address 2
City         State Zip
Police Or Fire Department To Which Loss Was Reported

Type Of Loss
Fire
Lightning
Internal Explosion
Windstorm or Hail
Explosion
Riot or Civil Commotion
Aircraft
Vehicle
Smoke
Vandalism or Malicious Mischief
Sprinkler Leakage
Other  (Explain)

Description Of Loss & Damage

Policy Information
Mortgagee
       Name 1  
       Name 2  
       Address 1
       Address 2
        City        State Zip
No Mortgagee

Loss Information
COMPLETE ONLY THOSE ITEMS INVOLVED IN LOSS

Item 1
Subject Of Insurance:
                                 Building
                                 Household Furnishings
                                  Contents
                                 Other Structure
                                  Time Element
                                 Other

Insurance Amount  ; % COINSURANCE
Deductible             
Coverage And/Or Description Of Property Insured

Item 2
Subject Of Insurance:
                                 Building
                                 Household Furnishings
                                  Contents
                                 Other Structure
                                  Time Element
                                 Other

Insurance Amount  ; % COINSURANCE
Deductible             
Coverage And/Or Description Of Property Insured

Item 3
Subject Of Insurance:
                                 Building
                                 Household Furnishings
                                  Contents
                                 Other Structure
                                  Time Element
                                 Other

Insurance Amount  ; % COINSURANCE
Deductible             
Coverage And/Or Description Of Property Insured

Remarks/Other Insurance (List companies, policy numbers, coverage, & policy amount)/ For NY only: previous address of insured & wife's maiden name)

Any person who knowingly and with intent to defraud any insurance company or other 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, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

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