FIRST NOTICE OF LOSS
HURRICANE DAMAGE
GB Account #: 010912
VDN: 2225720
Authority Name
*
Date of Loss
-
Month
-
Day
Year
Date
Reporting Party Name
*
First Name
Last Name
Reporting Party E-mail
*
example@example.com
Reporting Party Phone #
*
-
Area Code
Phone Number
Building Damage Details
Describe what happened, damages
Please be as detailed as possible
Type of Damage
Wind / Roof
Flooding (non-coastal)
Tidal Surge
Other Damage
Loss of Life
How Many Buidings Suffered Hurricane Damage?
1-3
4-9
10-20
All Structures
Has any damage mitigation effort begun? You are authorized to mitigate damage as soon as possible.
Tarps on damaged roofs
Pumps for water extraction
Board-up of broken windows
Fans for drying
Mitigation efforts will proceed soon
Locations Affected
NOT REQUIRED FOR REPORTING
City/Town/Village
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Please add any other significant information
0/500
Today's Date
-
Month
-
Day
Year
Date
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Vermont Fraud Advisement
VERMONT LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.
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