PROOF OF LOSS - All States

PROOF OF LOSS
Write your Email
example@example.com
Amount of Policy at Time of Loss
The Total Amount of insurance upon the property described by this policy was, at the time of the loss. Add up Coverage A-D in the policy. Do not add a $ sign.
Amount of Policy at Time of Loss
Amount of Policy at Time of Loss
The Total Amount of insurance upon the property described by this policy was, at the time of the loss
Policy Number
Date Issued

MonthDayYear
Date
Agency At
Insurance Company Address (or the IC agents address if IC address is not available)
Agent
Insurance Company Name
Date Expires

MonthDayYear
Date
Name of Insured(s)
If 2 Insureds, please write both names here and separate in the next lines.
Name of Insured
Name of Additional Insured
Leave Blank if None
Cause of Loss
Cause of Loss 1
Cause of Loss 2
Loss Address
Claim Number
Date of Loss

MonthDayYear
Date
Approximate Time of Loss

:HourMinutesAM/PM Option
**PLEASE CONFIRM DATE OF LOSS FALLS WITHIN POLICY PERIOD**
Type of Property
Mortgage Company
The Whole Loss and Damage Was ($) (Estimate Amount)
Amount of Deductible ($)
The Amount Claimed under the above numbered policy is ($)
Should be Empty: