Claims

Claim Notice of Loss

This form is for BROKER USE ONLY in the event of a loss.

  • Confirm with caller the best phone number that the insured can be reached. Please use remark section below if there are further contact instructions.
  • Brief description of loss - ie Water damage, Kitchen fire. Please provide further details in the remark section.
  • Please further describe the loss in detail.
  • Name of person/entity reporting claim to you
  • PROPERTY COVERAGES & FORM #'S

  • i.e. Plus, Broad, Standard, Basic, Comprehensive etc...
  • LIABILITY & COVERAGE

    Only complete this section if reporting a liability claim
  • CLAIMANT

    Only use for liability claims
  • Office Use Only