Seacoast Insurance LLC

Property Loss Notice

NOTE: ALL fields must be filled in in order for the form to SUBMIT. If you cannot complete a field, please enter N/A.

INSURED INFORMATION

Insured's Name:

 

Mailing Address:

 

City, State, ZIP:

 

Residence Phone:

          Business Phone:

    Cell Phone:

E-Mail:

LOSS INFORMATION - All fields are required (if not applicable, please show N/A).

Date of Loss:

Enter dates in this format 00/00/00

Date Reported:

Reported By:

Reported To:

Previously Reported:

Location of Loss:

If other location, please show address below.

Address:

Loss Reported to Authority?

If yes, name of authority:

Report # if available:

Other Insurance:

If yes, name of company:

Policy #:

Type of Loss:

 Fire Lightning Electrical Current
Smoke Vandalism Volcanic Eruption
Windstorm Theft Sinkhole Collapse
Hail Falling objects Flood

Explosion

 Accidental discharge

Wind

Riot

 Freezing

Other

Aircraft

Weight of ice, snow or sleet
  Vehicle

If other, please explain:

Estimated Loss Amount:

Description of Loss:

Remarks/Other Insurance:

OTHER CONTACT (Not Insured) INFORMATION

Contact's Name:

 

Mailing Address:

 

City, State, ZIP:

 

Residence Phone:

 

 

Business Phone:

 

 

Where to Contact:

 

 

When to Contact:

(Time)

 

 

POLICY INFORMATION

Homeowner

Company:

 

Policy Number:

 

Effective Date:

Expiration Date:

AOP Deductible:

Wind Deductible:
Water Damage Deductible:

Please complete the following if the company providing flood or wind is other than above.

Flood

Company:

Policy Number:

Effective Date:

Expiration Date:

Wind

Company:

Policy Number:

Effective Date:

Expiration Date: