First Notice of Loss Form - Property
To submit a New Assignment, please complete this form below and click on the Submit button. Please enter as much information as possible to expedite the investigation process. If you have any questions, please call (800)285-2524.
Required fields are in
bold
and noted with a *
* Reported By:
* Phone, (xxx) xxx-xxxx:
Contact Information
Name: (First)
(Last)
Address:
City:
State:
Zip Code:
Res. Phone, (xxx) xxx-xxxx:
Cell Phone:
Bus. Phone:
Email:
Policy Information
*Insured:
Please Select
Owner
Renter
Condo
* Name: (First)
* (Last)
Policy Number:
Address:
City:
State:
Zip Code:
* Res. Phone, (xxx) xxx-xxxx:
Cell Phone:
Bus. Phone:
Is there a Mortgagee?:
No
Yes
Mortgage Company:
* Remarks/Other Insurance:
Loss Information
* Date of Loss (MM/DD/YYYY):
Time of Loss (xx:xx):
AM
PM
* Location of Loss:
City:
State:
Police or Fire Dept to which Reported:
Probable Amount of Entire Loss:
Loss Type:
Please Select
Fire
Wind
Flood
Theft
Hail
Lightening
Other
Please Specify:
* Description of Loss and Damage:
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