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PROPERTY LOSS NOTICE

DATE (MM/DD/YYYY)

AGENCY

PHONE (A/C, No, Ext):

FAX (A/C, No):

E-MAIL ADDRESS:

CODE:

SUB CODE:

AGENCY CUSTOMER ID:

MISCELLANEOUS INFO (Site & location code)

DATE OF LOSS AND TIME

PREVIOUSLY REPORTED

YES

POLICY TYPE

COMPANY AND POLICY NUMBER

NAIC CODE

POLICY DATES

PROP/

CO:

EFF:

HOME

POL:

EXP:

CO:

EFF:

FLOOD

POL:

EXP:

CO:

EFF:

WIND

POL:

EXP:

INSURED

CONTACT

CONTACT INSURED

NAME AND ADDRESS OF INSURED

DATE OF BIRTH

NAME AND ADDRESS

SOC SEC # OR FEIN:

RESIDENCE PHONE (A/C, No)

BUSINESS PHONE (A/C, No, Ext)

E-MAIL ADDRESS:

NAME AND ADDRESS OF SPOUSE (IF APPLICABLE)

DATE OF BIRTH

RESIDENCE PHONE (A/C, No)

BUSINESS PHONE (A/C, No, Ext)

SOC SEC # OR FEIN:

WHERE TO CONTACT

WHEN TO CONTACT

LOSS

LOCATION OF LOSS

POLICE OR FIRE DEPT TO WHICH REPORTED

KIND

FIRE

LIGHTNING

FLOOD

OTHER (explain)

PROBABLE AMOUNT ENTIRE LOSS

OF LOSS

THEFT

HAIL

WIND

DESCRIPTION OF LOSS & DAMAGE (Use separate sheet, if necessary)

POLICY INFORMATION

MORTGAGEE

NO MORTGAGEE

HOMEOWNER POLICIES SECTION 1 ONLY (Complete for coverages A, B, C, D & additional coverages. For Homeowners Section II Liability Losses, use ACORD 3.)

A. DWELLING

B. OTHER STRUCTURES

C. PERSONAL PROPERTY

D. LOSS OF USE

DEDUCTIBLES

DESCRIBE ADDITIONAL COVERAGES PROVIDED

COVERAGE A. EXCLUDES WIND

SUBJECT TO FORMS (Insert form numbers and edition dates, special deductibles)

FIRE, ALLIED LINES & MULTI-PERIL POLICIES (Complete only those items involved in loss)

ITEM

SUBJECT OF INSURANCE

AMOUNT

% COINS

DEDUCTIBLE

COVERAGE AND/OR DESCRIPTION OF PROPERTY INSURED

BLDG

CNTS

BLDG

CNTS

BLDG

CNTS

SUBJECT TO FORMS (Insert form numbers and edition dates, special deductibles)

FLOOD

BUILDING:

DEDUCTIBLE:

ZONE

PRE FIRM

DIFF IN ELEV

FORM

GENERAL

CONDO

POLICY

CONTENTS:

DEDUCTIBLE:

POST FIRM

TYPE

DWELLING

WIND

BUILDING

DEDUCTIBLE

CONTENTS

ZONE

FORM

GENERAL

CONDO

POLICY

TYPE

DWELLING

REMARKS/OTHER INSURANCE (List companies, policy numbers, coverages & policy amounts)/NY ONLY: PREVIOUS ADDRESS OF INSURED & WIFE’S MAIDEN NAME

CAT #

FICO #

ADJUSTER

ADJUSTER #

DATE ASSIGNED

ASSIGNED

REPORTED BY

REPORTED TO

SIGNATURE OF INSURED

SIGNATURE OF PRODUCER