File a Property Claim

[[[["field31","equal_to","Yes"]],[["show_fields","field30"]],"or"],[[["field31","equal_to","No"],["field31","not_equal_to","Yes"],["field31","not_equal_to","No"]],[["hide_fields","field30"]],"or"],[[["field29","equal_to","Yes"]],[["show_fields","field33,field32"]],"and"],[[["field29","equal_to","No"],["field29","not_equal_to","Yes"],["field29","not_equal_to","No"]],[["hide_fields","field33,field32"]],"or"],[[["field65","equal_to","Other"]],[["show_fields","field66"]],"and"],[[["field65","not_equal_to","Other"]],[["hide_fields","field66"]],"and"],[[["field50","equal_to","Yes"],["field50","not_equal_to","Yes"],["field50","not_equal_to","No"]],[["hide_fields","field51,field52,field53,field54,field55,field56,field44,field58,field59,field60,field90"]],"or"],[[["field50","equal_to","No"]],[["show_fields","field51,field52,field53,field54,field55,field56,field44,field58,field59,field60,field90"]],"and"],[[["field83","equal_to","Other"]],[["show_fields","field84"]],"and"],[[["field83","not_equal_to","Other"]],[["hide_fields","field84"]],"and"]]
1 Page 1
2 Page 2
3 Page 3
4 Page 4
Property Claim
Report of Loss
Was the loss previously reported to us?
Claim or Reference Numberif available
Was the loss previously reported to another insurer?
Name of Insurer
Claim or Reference Numberif available
Agent or Broker Information
Name of Agent or Broker
Street Address
AddressLine 2 (optional)
City
ZIP
Daytime Phone
Evening Phone
Fax Number
Agency Code
Agency Sub-Code
Named Insured & Person to Contact
Named Insured
Street Address
AddressLine 2 (optional)
City
ZIP
Daytime Phone
Evening Phone
Fax Number
Agency Customer ID
Site or Location Code
Is contact info the same as named insured?
Contact Person Info
Name of Contact
Street Address
AddressLine 2 (optional)
City
ZIP
Daytime Phone
Evening Phone
Fax Number
Policy Information
Insurance Company
Policy Number
Policy Effective Date
Policy Expiration Date
Policy Type
Other Policy Type
Loss Information
Date of Loss
Time of Loss
Location of Losscity & state
Cause of lossfire, wind, hail, theft, etc.
Description of Loss
0 /
Authorities Contactedif applicable
0 /
Name & Contact Info of Witnessesinclude address, phone, email, etc.
0 /
Other Insurance Info
Insurance Company
Named Insured
Policy Number
Policy Expiration Date
Policy Type
Other Policy Type
Are you an additional insured on this policy?
Additional Comments
0 /
Previous
Next
If the form does not display, you may be using an unsupported browser (such as Internet Explorer 10 or earlier). We suggest updating your browser. Visit this site to update your browser.

Need a Different Form?

Workers’ CompAutoGeneral Liability