ACORD Property Loss Notice

Today's Date:

Agency and Loss Information

Agent:
Agent phone:
Code:
Sub Code:
Agency ID:
Miscellaneous Info:
Date of Loss:
Time of Loss:
Prev. Reported:
Yes No

Policy Types:

HOME/PROP Ins:
Effective Date:
Policy #:
Expiration Date:
NAIC Code:
FLOOD Insurer:
Effective Date:
Policy #:
Expiration Date:
NAIC Code:
WIND Insurer:
Effective Date:
Policy #:
Expiration Date:
NAIC Code:

Insured Information

Insured Name:
Date of birth:
Insured Address:
Soc Sec #:
Home Phone #:
Work Phone #:
*Spouse name:
*Spouse DOB:
*Spouse Address:
*Spouse SS#:
   *If applicable
Contact Insured:
Yes No
Where to Contact:
When to Contact:

Loss Information

Location of Loss:
Reported to:
Kind of Loss:
Fire Theft Lightning Hail Flood Wind Other
Describe Other:
Probable Loss Amt:
   Description of Loss:

Policy Information

Mortgagee:
No Mortgagee:
   Homeowner Policies Section 1 Only (Complete for coverages A, B, C, D & additional coverages
A. Dwelling:
B. Other Structrs:
C. Personal Prop.:
D. Loss of Use:
Deductibles:
Addt. Coverages:
Wind Exclusion (A):
Yes No
   Fire, Allied Lines & Multi-Peril Policies (complete only those items involved in loss)
Item 1:
Insurance Subject:
Bldg Cnts
Amount:
%Coins:
Deductible:
Description:
Item 2:
Insurance Subject:
Bldg Cnts
Amount:
%Coins:
Deductible:
Description:
Item 3:
Insurance Subject:
Bldg Cnts
Amount:
%Coins:
Deductible:
Description:
   Flood Policy
Building:
Bld. Deductible:
Contents:
Cnts. Deductible:
Zone:
Pre or Post Firm:
Pre Firm Post Firm
Elevation Diff:
Form Type:
General Dwelling Condo
   Wind Policy
Building:
Deductible:
Contents:
Zone:
Form Type:
General Dwelling Condo
   Remarks/Other Insurance:

Other Information

Category Number:
FICO Number:
Adjuster Assigned:
Adjuster Number:
Date Assigned:
Reported By:
Reported To: