New York Property Insurance Underwriting Association

Property Loss Notice

 
Policy Number             -
Policy Effective Date    / / (mm/dd/yy) Policy Expiration Date / / (mm/dd/yy)
Date Of Loss    / / (mm/dd/yy)               Time Of Loss   :

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  
  

(Explain)   

Description Of Loss






Policy Information

     Name 1     
     Name 2     
     Address 1  
     Address 2  
      City             State     Zip


Loss Information
COMPLETE ONLY THOSE ITEMS INVOLVED IN LOSS


Item 1
Subject Of Insurance:    (select one of  the field from below boxes) 






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

Item 2
Subject Of Insurance:      (select one of  the field from below boxes) 






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


Item 3
Subject Of Insurance:      (select one of  the field from below boxes) 






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.


Submitted By  
Your E-mail Address  
Confirm E-mail Address    

Use the following fields to upload any files(Photos,Reports,etc.),if needed ,as part of the loss notice submission .
Accepted file types : .pdf, .doc, .docx, .xls, .xlsx,.txt, .tif, .tiff, .jpg, .jpeg, .png, .gif and .giff
(Max size 10 MB)  
(Max size 10 MB)  
(Max size 4 MB)  
(Max size 4 MB)  
(Max size 4 MB)  
(Max size 4 MB)  
(Max size 4 MB)  
(Max size 4 MB)  
(Max size 4 MB)  
(Max size 4 MB)  


Once you click the 'Submit Form' button , please be patient to wait for your confirmation page. It may take up to a minute to process your entry.

 

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