Lemark Insurance Agency, Inc.
Property Loss Form
Property Loss Notice Form
PROPERTY LOSS NOTICE
You may use the form below to submit a property loss notice directly to one of our qualified agents. An agent from our office will contact you shortly after receiving the request. No claims will be bound until you recieve confirmation from our office upon review.
 

Policy Holder Information
Name Insured
(As it appears on the policy):
Address:
Phone #: Work     Home
Email:
Policy #:

Time and Description of Loss
Time & Date of Loss
Time a.m.
p.m.		 Date
Location of Property:
Description of Loss:

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

Authority Notification
Was the Police or Fire Dept. notified? Yes No
If Yes, which Authority?

Report Information
Reported by:
Title (if any):
Date:


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