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Property Loss Notice

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INSURED INFORMATION

First Name

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Last Name

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Street

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City

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State / Province

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ZIP / Postal Code

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Residence Phone

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Business Phone

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Cell Phone

Optional

E-Mail Address

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LOSS INFORMATION

Date of Loss

Required

Date Reported

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Reported By

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Reported To

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Previously Reported

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Location of Loss

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If other location, please show address

Optional

Loss Reported to Authority?

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Yes
No

If yes, name of authority

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Report # if available

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Other Insurance

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Yes
No

If yes, name of company

Optional

Policy #

Optional

Type of Loss

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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

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Estimated Loss Amount

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Description of Loss

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Remarks/Other Insurance

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OTHER CONTACT (Not Insured) INFORMATION

Contact's Name

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Mailing Address

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City

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State / Province

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ZIP / Postal Code

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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

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Effective Date

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Expiration Date

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AOP Deductible

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Wind Deductible

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Water Damage Deductible

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

Flood

Company Name

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Policy Number

Required

Effective Date

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Expiration Date

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Wind

Company Name

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Policy Number

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Effective Date

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Expiration Date

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