Instructions: Please make sure you have the following items prior to filling out this form: - Copy of your current policy - The Accident Report
Agency Information
Agency Name:
Agent Name:
Agent Phone Number:
Insured's Information
Named Insured
Address
Unit or Suite
Home Phone
Business Phone
Email Address
Zip Code:
Location:
Contact Information
Same as above?
Contact Name
Contact Address
Unit/Suite
Contact Phone
Contact Business Phone
Contact Email Address
Location and Loss Information
Same as contact?
Loss Location Address
Loss Location Unit/Suite
Date of Loss
Time of Loss
Policy Number
Policy Eff Date
Policy Exp date
Police or Fire Dept contacted
Police or Fire Dept Report Number
Type of Loss (Please put an X in the boxes that apply)
Fire?
Theft?
Lightning?
Hail?
Flood?
Wind?
Other?
Please describe loss...
Esitmated Loss Amount: