Agent Notice of Loss - Property and Liability "Combined Loss Notice"
Return to Policy Forms Bulleted List
*
- Denotes a required field
Date
Policy#
*
(This should be 13 characters starting with a letter)
Producer's Name
Producer's Address
Date of Loss
Time of Loss
AM or PM
AM
PM
Phone #
Policy Eff. Date
Policy Exp. Date
Insured:
Insured Name
Insured Address
Insured Home Phone #
Insured Business Phone#
Person to Contact
Contact's Daytime Phone#
Loss:
Location of Loss
Description of Loss & Damage
Kind of Loss
(Fire, Wind, Explosion, ETC.)
Probable Amount of Entire Loss
Injured/Property Damaged:
Name (of Injured/Owner)
Address
Phone#
Date of Birth
Sex
Male
Female
Employers Name
Employers Address
Employers Phone#
Describe What Injured Was Doing/Describe Injury
Where Was The Injured Taken?
Describe Property Damage
Where Can Property Be Seen?
Estimate Amount
Witness:
Name of Witness #1
Address of Witness #1
Business Phone Witness #1
Home Phone Witness #1
Name of Witness #2
Address of Witness #2
Business Phone Witness #2
Home Phone Witness #2
Name of Witness #3
Address of Witness #3
Business Phone Witness #3
Home Phone Witness #3
Miscellaneous:
Miscellaneous
*
- Denotes a required field
Fulmont Mutual Insurance Company
P.O. Box 487, Johnstown, NY 12095-0487
E-Mail:
info@fulmontmutual.com
Copyright Fulmont Mutual Insurance Company. All Rights Reserved.
This web site was developed by
Empire Web Pages
.
Maintained by Fulmont Mutual Insurance Company.
This page was most recently updated on June 26, 2018.