Date: *Policy Type:
Date of Loss:*Policy Number:
Agency: Previously Reported: YesNo
Agency Phone:Time of Loss:AMPM
Insured InfoContact Info
Name: *Name:
Address:Residence Phone #:
City:Business Phone #:
Zip:Cell Phone #:
Residence Phone #: *Email Address:
Business Phone #:Where to Contact:
Cell Phone #:When to Contact:
Email Address:
Police or Fire Department to Which Reported:
Probable Amount of Entire Loss:
*Location of Loss (include City & State): 
*Description of Loss: 
Reported By:
"Any person who knowingly and with intent to defraud any insurance company or other person files and application for insurance or statement of claim containing any materially false informaiton, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."
The person completing this Loss Notice hereby affirms that the statements and representations made herein are true to the best of his/her knowledge.