Property Damage Loss Report

Provide all documents you have regarding this incident.
Copy of lawsuit, if filed
Documents provided by claimant including medical bills.
Internal documents including any investigation of the incident, repair and maintenance records, etc.
Names and address of any witnesses to the incident or employees who may be able to provide details on the product
or location involved in the incident.
If a product is involved & you have the product, save this for inspection by the claims adjuster or an expert named by
the insurance company.
The claim adjuster will deal directly with the claimant or his/her attorney; you should not deal with them yourself.
Expect to be contacted by the claims adjuster within 48 hours.
If there is any reason that you need to be contacted immediately, please let us know.

Date

Insured Name

First Last

Address / Loss Location

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Description of Loss

Extent of Loss

EFFECT ON BUSINESS

Is the damaged property necessary for the insured to continue operating in any way?

Tell us what product line you're interested in and an expert who is best suited to your needs will be in touch within the next business day.