NOTICE OF CLAIM

NOTICE OF CLAIM

For assistance, please email: clients@novarisktransfer.com or call (833)-378-3523
Date of Loss (Start and End Date; if loss occurrence is ongoing please only list the claim start date):

MonthDayYear
Date
Nova Policy Number:
Part 1: Policy Holder
Name of Insured
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Part 2: Contact Information
Name of Contact Responsible for Claim Submission

First NameLast Name
Email

Primary EmailSecondary Email
Name of Contact Responsible for Claim Handling:

First NameLast Name
Email

Primary EmailSecondary Email
Part 3: Loss Occurrence
Covered Loss Line Description Under Which Claim is Being Made:
Loss Amount Claimed:
Description of Occurrence (in the space provided below, please provide a full description that includes all information relevant to the occurrence and subsequent claim being made):
Part 4: Attachments
Please attach all documentation pertaining to the claim that supports the claimed amount and how the total claim amount was determined.
- If property damage: original cost new of the items and the basis (Cost of Repair, Actual Cash Value, Replacement Cost, Market Value) of what is being claimed.
- If loss of profits or earnings, method of determination with supporting documentation, e.g. Financial Statements year over previous year adjusted for increased sales or unrelated loss of business, etc.
- If expense reimbursement: documentation of loss event and receipts or invoices along with proof of payment.
File Upload

Cancelof
I warrant the information on this Claim Form is true and correct and that all representations on this form are accurate. I understand that misstatements may void the validity of this loss:

NameAuthorized Individual Name
Should be Empty:

NOTICE OF CLAIM

Part 1: Policy Holder

Part 2: Contact Information

Part 3: Loss Occurrence

Part 4: Attachments