PROPERTY LOSS NOTICE
Date (MM/DD/YYYY)
I am the
Agent
Insured
Contact
Agency
Address
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Phone (A/C, No., Ext)
Fax (A/C, No., Ext)
Email Address
Code
SubCode
Agency Customer ID
Miscellaneous Info (Site & Location Code)
Date and Time of Loss
AM
PM
Previously Reported
Yes
No
Policy Type
Prop/Home
Flood
Wind
Policy Number
Effective Date
Expiration Date
INSURED
Name of Insured (First, Middle, Last)
Date of Birth
Soc Sec # or FEIN
Mailing Address
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Primary Phone #
Home
Bus.
Cell
Secondary Phone #
Home
Bus.
Cell
Primary Email Address
Secondary Email Address
Spouse's Name (if applicable)
Date of Birth
Soc Sec # or FEIN
Mailing Address (if different from Insured)
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
CONTACT
Contact Insured
Name of Contact (First, Middle, Last)
Primary Phone #
Home
Bus.
Cell
Secondary Phone #
Home
Bus.
Cell
Where to Contact
When to Contact
Contact's Mailing Address
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Primary Email Address
Secondary Email Address
LOSS
Location of Loss
Street
City, State, Zip
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Police or Fire Department Contacted
Report Number
Kind of Loss
Fire
Theft
Lightning
Hail
Flood
Wind
Other
If Other, please specify
Probable Amount Entire Loss
Description of Loss & Damage
POLICY INFORMATION
Mortgagee
Homeowner Policies Section I Only (Complete for coverages A, B, C, D & additional coverages.
For Homeowners Section II Liability Losses, use GL Loss Notice Form.)
Coverage A.
Dwelling
$
Coverage B.
Other
Structures
$
Coverage C.
Personal
Property
$
Coverage D.
Loss of Use
$
Deductibles
$
Coverage A Excludes Wind
Describe Additional Coverage Provided
$
on
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
Building
Contents
Other
Building
Contents
Other
Building
Contents
Other
If Other,
Please Specify
Amount
$
$
$
% Coins
Deductible
$
$
$
Coverage and/or Description
of Property Insured
Subject to Forms (Insert form numbers and edition dates, special deductibles)
FLOOD POLICY
Building
Deductible
$
Contents
Deductible
$
Zone
Pre/Post Firm
Pre Firm
Post Firm
Diff in Elev.
Form Type
General
Dwelling
Condo
Other
If Other, Please Specify
WIND POLICY
Building
Deductible
$
Contents
Zone
Form Type
General
Dwelling
Condo
Other
If Other, Please Specify
Claim Number (FOR INTERNAL USE ONLY)
Remarks/Other Insurance (List companies, policy numbers, coverages & policy amounts) / NY ONLY: Previous Address of Insured & Wife's Maiden Name
CAT #
FICO #
Adjuster Assigned
Adjuster #
Date Assigned
Reported By
Reported To
APPLICABLE IN ARIZONA For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. APPLICABLE IN ARKANSAS, DELAWARE, DISTRICT OF COLUMBIA, KENTUCKY, LOUISIANA, MAINE, MICHIGAN, NEW JERSEY, NEW MEXICO, NEW YORK, PENNSYLVANIA, TENNESSEE, VIRGINIA AND WEST VIRGINIA Any person who knowingly and with intent to defraud any insurance company or another 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, subject to criminal prosecution and [NY: substantial] civil penalties. In DC, LA, ME, TN and VA, insurance benefits may also be denied. APPLICABLE IN CALIFORNIA For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. APPLICABLE IN COLORADO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. APPLICABLE IN FLORIDA AND IDAHO Any person who Knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim Containing any False, Incomplete or Misleading information is Guilty of a Felony.* * In Florida - Third Degree Felony APPLICABLE IN HAWAII For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. APPLICABLE IN INDIANA A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. APPLICABLE IN MINNESOTA A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. APPLICABLE IN NEVADA Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony. APPLICABLE IN NEW HAMPSHIRE Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. APPLICABLE IN OHIO Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. APPLICABLE IN OKLAHOMA WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
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