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Serving the low country since 1981

Homeowners Auto Flood Boat Business

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 *

Last Name *

Street *

City *

State / Province *

ZIP / Postal Code *

Residence Phone *

Business Phone *

Cell Phone

E-Mail Address *

LOSS INFORMATION

Date of Loss *

Date Reported *

Reported By *

Reported To *

Previously Reported *

Location of Loss *

If other location, please show address

Loss Reported to Authority? *

Yes
No

If yes, name of authority

Report # if available

Other Insurance *

Yes
No

If yes, name of company

Policy #

Type of Loss

Fire
Smoke
Windstorm
Hail
Explosion
Riot
Aircraft
Vehicle
Lightning
Vandalism
Theft
Falling Objects
Accidental discharge
Freezing
Weight of ice, snow, or sleet
Electrical Current
Volcanic Eruption
Sinkhole Collapse
Flood
Wind
Other

If other, please explain

Estimated Loss Amount *

Description of Loss *

Remarks/Other Insurance *

OTHER CONTACT (Not Insured) INFORMATION

Contact's Name *

Mailing Address *

City *

State / Province *

ZIP / Postal Code *

Residence Phone *

Business Phone *

Where to Contact *

When to Contact *

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POLICY INFORMATION

Homeowner

Company Name *

Policy Number *

Effective Date *

Expiration Date *

AOP Deductible *

Wind Deductible *

Water Damage Deductible *

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

Flood

Company Name *

Policy Number *

Effective Date *

Expiration Date *

Wind

Company Name *

Policy Number *

Effective Date *

Expiration Date *

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