Please fill out all sections as completely as possible. When submitted you will receive a copy that you can print for your files

Agent Name:

Agency Number:

Policy Number:

Date Reported:

Policy Holder:

Policy Holder Phone Number:

Date of Loss:

Filed By: Agent Policy Holder

Loss Information If claim includes Liability please use Other to explain

Type of Loss:      Fire Lightning Wind Hail Flood Theft Other

Deductible:      $100 $250 $500 $1,000 $2,500 No Deductible

Amount of Loss

Description of Loss: be as complete as possible.

Other: type of loss--explain if liabilityis involved, include claimants name, address and phone number and any other information

= Required