Loss Report Form
	GENERAL INFORMATION
	Date:
	Loss Reported By:
	Agent:
	Type of Policy:	Please Specify    Residential Commercial
	Policy Number:
	Deductible ($):
	Name of Insured:
	Address:
	Postal Code:
	Telephone (home):
	Telephone (cell):
	Telephone (work):
	Telephone (fax):
	LOSS DESCRIPTION
	Date of Loss:
	Time of Loss:	AM   PM
	Location of Loss:
	Postal Code:
	Reported to Police:	Yes   No
	Policy Case Number:
	Loss Details:
	SCHEDULE OF LOSS (PLEASE USE SEPARATE SHEET, IF NECESSARY)
	DESCRIPTION OF PROPERTY WHEN & WHERE PURCHASED ORIGINAL COST REPLACEMENT COST AMOUNT CLAIMED