First Notice of Loss (FNOL)

REPORT A CLAIM

SafeHerb (Cannabis)
REPORTING PARTY INFORMATION

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

AttorneyBroker / Insurance AgentClaimant / Injured PartyInsured / PolicyholderOther
Reporter Name*

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

MonthDayYear
Date
Location of Loss / Accident*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code (5 digits)
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.
Please describe any Injuries resulting from the Loss/Accident*
Describe in detail injuries sustained, body part(s). Hospital & Physician Name(s) - contact information.
PARTY INFORMATION - WHO WAS INVOLVED?

Person(s) involved in the Loss / Accident
Full Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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 Loss/Accident, Contact Information, Comments/Details
INVESTIGATION / DISCOVERY
Police Report*

Yes - please complete Police Department Name and Police Report NumberNoUnknown
Police Department Name, if applicable
Police Report Number, if applicable
Attach Supporting Documents - Example: Incident Report, Photos, Videos

Any documents related to the Accident/Loss
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, other Party to the Loss (please include name/phone number)
CLAIMS CONTACT INFORMATION
Avant Specialty Claims

Email: claims@avantclaims.com

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 TransportMotor Vehicle Accident - Multiple parties involvedPolice / 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

LOSS INFORMATION

PARTY INFORMATION - WHO WAS INVOLVED?

Other Party Information - if applicable

INVESTIGATION / DISCOVERY

CLAIMS CONTACT INFORMATION