Agent Notice of Loss - Property and Liability
"Combined Loss Notice"
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PRODUCERS NAME & ADDRESS:
 DATE:


POLICY #:

 

DATE OF LOSS:
 a.m.   p.m. 		TIME OF LOSS:
 a.m.   p.m.
PHONE NO.:
 POLICY EFF. DATE:
 		POLICY EXP. DATE:
Insured:
INSURED NAME AND ADDRESS:
 PERSON TO CONTACT:
CONTACTS DAYTIME PHONE NUMBER:
INSURED’S HOME PHONE NO.:
 INSURED’S BUSINESS PHONE NO.:
Loss:
LOCATION OF LOSS:
   
DESCRIPTION OF LOSS & DAMAGE: (Note, please limit your description to no more than 10 rows. Anything more than 10 may not print.)

KIND OF LOSS (FIRE, WIND, EXPLOSION, ETC.):
 PROBABLE AMOUNT OF ENTIRE LOSS:
Injured/Property Damaged:
NAME & ADDRESS (INJURED/OWNER):
 PHONE NO.:
DATE OF BIRTH:
 		SEX:
M F 		OCCUPATION/EMPLOYERS NAME & ADDRESS:
OCCUPATION/EMPLOYERS PHONE NO.:
DESCRIBE WHAT INJURED WAS DOING/DESCRIBE INJURY:
 		WHERE TAKEN?
DESCRIBE PROPERTY DAMAGED:
 		WHERE CAN PROPERTY BE SEEN?:
ESTIMATE AMOUNT:
Witnesses:
NAME AND ADDRESS#1:
 BUSINESS PHONE NO#1.:
RESIDENCE PHONE NO.#1:
NAME AND ADDRESS#2:
 BUSINESS PHONE NO#2.:
RESIDENCE PHONE NO.#2:
NAME AND ADDRESS#3:
 BUSINESS PHONE NO#3.:
RESIDENCE PHONE NO.#3:
Miscellaneous:
WE ARE REQUIRED BY LAW TO ADVISE YOU THAT, "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim

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