First Notice of Loss (FNOL)

REPORT A CLAIM

AVANT SUPERMARKET GROUP (ASG)
REPORTING PARTY INFORMATION

Your relationship to the claim
Loss/Accident Reported by:*

Insured / PolicyholderBroker / Insurance AgentAttorneyClaimant / Injured PartyOther
Reporter Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Acknowledgement Email(s) for Claim- Name & Email Address*
Who should receive an email of claim receipt.
POLICYHOLDER (INSURED) INFORMATION
Policyholder (Insured) Name
Policy Number
Policy Number can be found on the Declarations Page
Did the Loss/Accident happen to the Policyholder (Insured)?*

YesNo
*NOTE: If your Loss/Accident is outside the reporting period (policy inception-policy expiration date), please contact your Broker/Insurance Agent for additional assistance.
STORE INFORMATION
Store Name*
Store Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code (5-digits)
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Property Claim Information
Type of Property Loss:

FireFloodHailWindFood SpoilageLightningTheftEquipment BreakdownOtherNot Applicable (N/A)
Probable amount of Loss ($$)
Example: $xxxxx.xx
Customer Claim Information

Person(s) involved in the Loss/Accident - NOT the Policyholder/Insured
Full Name

First NameLast Name
Customer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
LOSS INFORMATION
Date of Loss/Accident*

MonthDayYear
Date
Time of the Loss/Accident

Hour Minutes
AM or PM*

AMPM
Location of Loss / Accident*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Description of Loss / Accident *
Describe in detail what happened. How did it happen? Why did it happen? Who was involved? Please include as much detailed information, as possible.
Were any of the following affiliated with the Loss/Accident? - please check all that may apply.

FloorsCartsPerson(s)LightingForeign matters or defectsOther
Was a Medical Provider seen?

YesNoUnknown
Is Medical treatment ongoing?

YesNoUnknown
Please describe any Injuries resulting from the Loss/Accident*
Describe in detail injuries sustained, all body part(s), nature of Injury
Medical Provider Contact Information
Please include Name, Address, Phone Number, appointment date(s)
Other Party Information - if applicable

Person(s) involved in the Loss/Accident - NOT the Policyholder/Insured
Full Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Information regarding "Other Party"
Additional parties involved in the Accident/Loss, Contact Information, Comments/Details
INVESTIGATION / DISCOVERY
Attach "INCIDENT REPORT" and Documents

Documents could include Photos, Videos, Police Report or other related materials. .
Cancelof
Were there any Witnesses to the Loss/Accident?*

YesNoUnknown
Witness Contact Information

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Comments/Discovery for consideration.
This could be additional details/comments
CLAIMS CONTACT INFORMATION
Avant Specialty Claims

Email: asgclaims@avantins.com

Phone: 816-251-1670
New Loss Reporting: 877-245-3823
Customer Support Team: 800-542-2441

Mailing Address:

Avant Specialty Claims
Division of Specialty Program Group (SPG)
PO Box 5188
El Dorado Hills, CA 95762
Is this an escalated claim? *** Immediate Attention ***

Medical Emergency - Hospital TransportPolice / Fire / Paramedic ResponseCatastrophic Event (Hurricane, Fire, Flood, Tornado, etc.)FatalityUrgent Contact Request (Other)
Additional details regarding escalated claim request...
Purpose for escalation, additional details/facts/concerns
Fraud Warning:

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 confinment in prison.
Submission Date
Should be Empty:

REPORT A CLAIM

REPORTING PARTY INFORMATION

POLICYHOLDER (INSURED) INFORMATION

STORE INFORMATION

Property Claim Information

Customer Claim Information

LOSS INFORMATION

Other Party Information - if applicable

INVESTIGATION / DISCOVERY

CLAIMS CONTACT INFORMATION

Avant Specialty Claims