Independent Insurance Center / Firemark -- Property Loss Notice

PROPERTY
LOSS NOTICE Please use the form below to notify us of any loss or damage to your property insured through this company/agency. Please note that this form is for notification purposes only and does not constitute making an actual claim. One of our representatives will contact you shortly after receiving this notification.

Policy Holder Information
Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.
Name Insured:
Address:
Phone #:	Work Home
Email:

Time and Description of Loss

Time & Date of Loss

Time a.m.
p.m. Date

Location of Property:

Description of Loss:

Authority Notification

Were the Police or Fire Dept. Called? Yes No

If Yes, which Authority?

Property Status

Is the Property habitable? Yes No

If No, where are you staying: (Address and Telephone)

Report Information

Reported by:

Title (if any):

Date:

Additional Comments

Please give any additional comments you feel appropriate for this Loss Notice.

Please click on the "Submit Form" button to send your Loss Notice.
One of our representatives will respond to your submission as soon as possible.


PROPERTY LOSS NOTICE		Please use the form below to notify us of any loss or damage to your property insured through this company/agency. Please note that this form is for notification purposes only and does not constitute making an actual claim. One of our representatives will contact you shortly after receiving this notification.

Authority Notification
Were the Police or Fire Dept. Called?	Yes No
If Yes, which Authority?

Property Status
Is the Property habitable?	Yes No
If No, where are you staying:	(Address and Telephone)