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Property Loss Notice

"*" indicates required fields

1Named Insured

2Contact

3Claimant

4Loss

5Final Remarks

Step 1: Named Insured

I am the*

Agency

Named Insured*

Policy Number*

Mailing Address

City

State

ZIP Code

Primary Phone Number*

Primary Phone Type*

Home

Bus.

Cell

Secondary Phone Number

Secondary Phone Type

Home

Bus.

Cell

Email*

* indicates required field

Step 2: Contact

Same Name

Contact Info is the same as Named Insured

Name of Contact (First, Middle, Last)

Primary Phone Number

Primary Phone Type

Home

Bus.

Cell

Secondary Phone Number

Secondary Phone Type

Home

Bus.

Cell

Contact's Mailing Address

City

State

ZIP Code

When to Contact

Step 3: Claimant

Name (Injured/Owner)

Contact's Mailing Address

City

State

ZIP Code

Primary Phone Number

Primary Phone Type

Home

Bus.

Cell

Step 4: Loss

Address of Liability Occurrence*

City*

State*

ZIP Code*

Date of Occurrence*

MM slash DD slash YYYY

Description of Liability Occurrence*

Describe Injury/Property Damage

Witness Information

* indicates required field

Step 5: Final Remarks

Remarks/Other Insurance (list companies, policy numbers and coverages)

Reported By

Reported To

Disclaimer*

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

By checking this box, I acknowledge that I have read and understand the above disclaimer.

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Property Loss Notice

GBLI | Global Indemnity

GBLI |
Global Indemnity