Insurance Claim Form

*All fields must be complete for a claim to be processed.
Notice Of Loss

Georgia Underwriting Association
Date of Loss
Policy Number
Include Dashes
Insured Name

First NameLast Name
Reported By
Insured Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured Phone Number

Area CodePhone Number
Alternate Number

Area CodePhone Number
Location Of Loss
Current Mortgagee
Type of Loss
Severity Code
Remarks & Instructions
Enter the message as it's shown
SEVERITY 1: Minor interior/exterior damage, roof damage less than 25%, Minor fire, light smoke 1 to 3 rooms lightning to A/C

SEVERITY 2: Roof damage > 50%, moderate fire damage, smoke more than 3 rooms, water damage to 2 or more rooms, lightning damage to A/C or appliances

SEVERITY 3: Structural damage; Extensive smoke / fire / water damage; building untenantable

SEVERITY 4: Extent of damage, from whatever covered cause deems building a constructive or obvious total loss
Should be Empty: