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PROPERTY LOSS

  • Please provide as much information about the claim as possible
  • Required fields are marked by the * symbol.
  • If you do not have the information for a required field, please enter "unknown".
Claim Details and Assignment Type
* DOL (mm/dd/yyyy) * Claim/file # Policy #

Cat Code

Type of Property Involved
Residential Commercial Industrial

Description of Loss

* General Assignment Instructions


Client Information/Reporting Address
* Client Company Name

* First Name

* Last Name

Mailing Address

Building/Suite

City

State

Zip

* Phone #

Fax #

* E-Mail


Insured Name and Contact Information
* Insured First Name Middle * Last Name

Company Name

Address 1

Address 2

City

* State

Zip

* Phone #

Other Phone #

Fax #

Policy Information and Coverage Details
  Limit Deductible Coinsurance Forms
Coverage A
Coverage B
Coverage C
Coverage D
Other

Other Information Concerning Coverage Instructions / Other Insured Information


Agent Information
Agent First Name Middle Last Name

Agency/Broker Company Name

Address 1

Address 2

City

State

Zip

Phone #

Other Phone #

Fax #
Instructions/Other Information Regarding the Agent


Information On Other Parties

Please use the following section for identifying additional parties to the loss, such as eye-witnesses, police officers, attorneys, etc. (Not Required).


Additional Party is:


Claimant Witness Other

First Name

Middle

Last

Company

Address 1

Address 2

City

State

Zip

Phone

Other Phone

Fax

Additional Information/Special Instructions
* Confirm Assignment Receipt
E-Mail Phone 1st Report

Report Within
1-3 Days 3-7 Days 7-15 Days 15-30 Days

Final Comments

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