PROPERTY LOSS NOTIFICATION
This form is to notify us of any loss or damage to your property insured through this agency. Please note that this form is for notification purposes only and does not constitute making an actual claim. One of our representatives will contact you shortly after receiving this notification. 

STATEMENT OF UNDERSTANDING
I understand that this form does not constitute an actual claim, but is a notification to our agency of an existing loss or claim, and may help expedite the claim process once submitted.
 
           I have read and agree with the above Statement of Understanding.
                            (Box must be checked before request can be sent)

                                        Policy Holder Information                                        
Please supply your phone numbers and email address
so that we may contact you after receiving your notification.

Name Insured:

Insured Address:
Phone #:  Work  Home Mobile
Email Address:  

Time and Property Damaged Description
Time: a.m.  p.m.                    Date of Damage:

Location of Property

Description of Damage

Authority Notification

       Police Called?  Yes   No                                Fire Dept., Called?  Yes   No  

Property Status
 Is the Property habitable? Yes   No             If No, state your current address and phone number
 

Person Reporting Information

Reported by: 

Relationship to Property:

Date: 

                                                  Additional Comments                                      
Please give any additional comments you feel appropriate for this NOTIFICATION.