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Seacoast Insurance

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Property Loss Notice

ALL fields must be filled in in order for the form to SUBMIT. If you cannot complete a field, please enter N/A.

INSURED INFORMATION

First Name

Required

Last Name

Required

Street

Required

City

Required

State / Province

Required

ZIP / Postal Code

Required

Residence Phone

Required

Business Phone

Required

Cell Phone

Optional

E-Mail Address

Required

LOSS INFORMATION

Date of Loss

Required

Date Reported

Required

Reported By

Required

Reported To

Required

Previously Reported

Required

Location of Loss

Required

If other location, please show address

Optional

Loss Reported to Authority?

Required

Yes
No

If yes, name of authority

Optional

Report # if available

Optional

Other Insurance

Required

Yes
No

If yes, name of company

Optional

Policy #

Optional

Type of Loss

Optional

FireSmoke
WindstormHail
ExplosionRiot
AircraftVehicle
LightningVandalism
TheftFalling Objects
Accidental dischargeFreezing
Weight of ice, snow, or sleetElectrical Current
Volcanic EruptionSinkhole Collapse
FloodWind
Other

If other, please explain

Optional

Estimated Loss Amount

Required

Description of Loss

Required

Remarks/Other Insurance

Required

OTHER CONTACT (Not Insured) INFORMATION

Contact's Name

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Mailing Address

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City

Required

State / Province

Required

ZIP / Postal Code

Required

Residence Phone

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Business Phone

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Where to Contact

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When to Contact

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POLICY INFORMATION

Homeowner

Company Name

Required

Policy Number

Required

Effective Date

Required

Expiration Date

Required

AOP Deductible

Required

Wind Deductible

Required

Water Damage Deductible

Required

Please complete the following if the company providing flood or wind is other than above.

Flood

Company Name

Required

Policy Number

Required

Effective Date

Required

Expiration Date

Required

Wind

Company Name

Required

Policy Number

Required

Effective Date

Required

Expiration Date

Required

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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Physical Address

88A Main Street
Hilton Head island, SC 29926
Phone: (843) 681-4340
Fax: (843) 681-8373
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