Client/Agency Information
Co. Claim No.
Policy No.
Policy Dates
From
To
Renewal
Yes
No
Insurance Company
Insurance Company
Address 1
Address 2
City
State
Zip Code
Attention
Phone
Fax
E-mail
Agent and Address
Last Name or Business
First Name
Address 1
Address 2
City
State
Zip Code
Phone Number
Policyholder/Contact Information
Insured #1 At Time of Loss
Last Name or Business
First Name
Address 1
Address 2
City
State
Zip Code
Contact Name
Contact Phone
Home
Work/Business
Ext.
Alternate
Best Time
Email
Insured #2 At Time of Loss
Last Name or Business
First Name
Coverage/Interests
Amount of Coverage
Co-Insurance
Deductible
ON
Basic Dwelling
Basic Contents
Homeowner - Dwelling
Homeowner - Other Structure(s)
Homeowner - Contents
Homeowner - Loss of Use
Homeowner - Other
100%
90%
80%
70%
60%
50%
ON
Basic Dwelling
Basic Contents
Homeowner - Dwelling
Homeowner - Other Structure(s)
Homeowner - Contents
Homeowner - Loss of Use
Homeowner - Other
100%
90%
80%
70%
60%
50%
ON
Basic Dwelling
Basic Contents
Homeowner - Dwelling
Homeowner - Other Structure(s)
Homeowner - Contents
Homeowner - Loss of Use
Homeowner - Other
100%
90%
80%
70%
60%
50%
ON
Basic Dwelling
Basic Contents
Homeowner - Dwelling
Homeowner - Other Structure(s)
Homeowner - Contents
Homeowner - Loss of Use
Homeowner - Other
100%
90%
80%
70%
60%
50%
ON
100%
90%
80%
70%
60%
50%
Form Numbers
Mortagee/Lien Holder or Other Interests
Last Name or Business
First Name
Mortagee/Lien Holder or Other Interests #2
Last Name or Business
First Name
Loss Information/Type of Assignment
If the loss location is the same as Insured #1, please insert "same" in the Address 1 below.
Address 1
Address 2
City
State
Zip Code
Date of Loss
Type of Assignment
Full Assignment
Limited - See handling instructions
Basic
Full Appraisal
Description of Loss
Specific Handling Instructions