Property Loss Notice

Policy Holder Information
Name Insured:
Address:
Phone #:	Work     Home
Email:

Time and Description of Loss
Time & Date of Loss	Time a.m. p.m. Date
Location of Property:
Description of Loss:

Authority Notification
Were the Police or Fire Dept. Called?	Yes     No
If Yes, which Authority?

Property Status
Is the Property habitable?	Yes     No
If No, where are you staying:	(Address and Telephone)

Report Information
Reported by:
Date:
Signature:	___________________________________________