New York Property Insurance Underwriting Association

 

Windstorm Loss Notice

Date of Loss / / (mm/dd/yy)     
1. INSURED
Policy Number -
Name 1
Name 2
Address 1
Address 2
City    State    Zip  
2. CONTACT
Name of Contact Person /Public Adjuster
Home Phone Number - -
Cell Phone Number - -
Work Phone Number - -
Primary E-mail Address
Secondary E-mail Address
3. LOSS
LOCATION OF LOSS
Address 1
Address 2
City    State     Zip
DESCRIPTION OF LOSS AND DAMAGE
CAUSE
PROPERTY AFFECTED
NATURE AND EXTENT OF DAMAGE

4 . DAMAGE

AREA OF DAMAGE     SLIGHT
  ($1-$5,000)		      MODERATE
   ($5,001-$10,000) 		      SEVERE
   ($10,000+)
EXTERIOR
 
INTERIOR
CONTENTS
OTHER STRUCTURES
OTHER-SPECIFY
IF YOU CHECKED OTHER, PLEASE SPECIFY HERE:

Use the following fields to upload any files (Photos, Reports - Estimates, Repair Bills, etc.), if needed , as part of the loss notice submission .
(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)  

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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