Fillable PROPERTY LOSS NOTICE INSURED AM NOYES PM CONTACT (Crum & Forster Insurance)

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PROPERTY LOSS NOTICE INSURED AM NOYES PM CONTACT (Crum & Forster Insurance)

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REMARKS/OTHER INSURANCE (List companies, policy numbers, coverages & policy amounts)/NY ONLY: PREVIOUS ADDRESS OF INSURED & WIFE'S MAIDEN NAME
NO MORTGAGEE
MORTGAGEE
SUBJECT TO FORMS
(Insert form numbers
and edition dates,
special deductibles)
CNTSBLDG
CNTSBLDG
CNTSBLDG
FIRE, ALLIED LINES & MULTI-PERIL POLICIES (Complete only those items involved in loss)
ITEM SUBJECT OF INSURANCE AMOUNT % COINS DEDUCTIBLE COVERAGE AND/OR DESCRIPTION OF PROPERTY INSURED
FLOOD
POLICY
BUILDING:
CONTENTS:
DEDUCTIBLE:
DEDUCTIBLE:
ZONE
PRE FIRM
POST FIRM
DIFF IN ELEV
FORM
TYPE
GENERAL
DWELLING
CONDO
WIND
POLICY
BUILDING DEDUCTIBLE CONTENTS ZONE
FORM
TYPE
GENERAL
DWELLING
CONDO
DATE ASSIGNEDADJUSTER #
ASSIGNED
ADJUSTER
FICO #CAT #
SIGNATURE OF PRODUCERSIGNATURE OF INSUREDREPORTED TOREPORTED BY
POLICY INFORMATION
ON
and edition dates, special deductibles)
SUBJECT TO FORMS (Insert form numbers
COVERAGE A. EXCLUDES WIND
HOMEOWNER POLICIES
A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY D. LOSS OF USE DEDUCTIBLES DESCRIBE ADDITIONAL COVERAGES PROVIDED
CELL PHONE (A/C, No)
NAME AND ADDRESS
E-MAIL ADDRESS
RESIDENCE PHONE (A/C, No) BUSINESS PHONE (A/C, No, Ext)
FAX (A/C, No) WHEN TO CONTACT
CONTACT INSUREDCONTACT
BUSINESS PHONE (A/C, No, Ext)RESIDENCE PHONE (A/C, No)
SOC SEC # OR FEIN:
INSURED
DATE OF BIRTHNAME AND ADDRESS OF INSURED
DATE OF BIRTH
NAME AND ADDRESS OF SPOUSE (IF APPLICABLE)
SOC SEC # OR FEIN:
E-MAIL ADDRESS
CELL PHONE (A/C, No)
AGENCY
(A/C, No):
FAX
E-MAIL
ADDRESS:
PHONE
(A/C, No, Ext):
AGENCY CUSTOMER ID:
CODE: SUB CODE:
DATE (MM/DD/YYYY)
PROPERTY LOSS NOTICE
EXP:
EFF:
POL:
CO:
WIND
EXP:
EFF:
POL:
CO:
FLOOD
EXP:
EFF:
POL:
CO:
HOME
PROP/
POLICY
TYPE
COMPANY AND POLICY NUMBER NAIC CODE POLICY DATES
NOYES
REPORTED
PREVIOUSLY
PM
AM
DATE OF LOSS AND TIMEMISCELLANEOUS INFO (Site & location code)
DESCRIPTION OF LOSS & DAMAGE (Use separate sheet, if necessary)
KIND
OF LOSS
FIRE
THEFT
LIGHTNING
HAIL
FLOOD
WIND
OTHER
(explain)
PROBABLE AMOUNT ENTIRE LOSS
LOCATION
OF LOSS
POLICE OR FIRE DEPT TO WHICH REPORTED/INCIDENT #
LOSS
08/04/2016
Submit By Email
* In Florida - Third Degree Felony
Any person who knowingly and with the intent to injure, defraud, or deceive any insurance company files a statement
of claim containing any false, incomplete or misleading information is guilty of a felony.*
Applicable in Florida and Idaho
Applicable in Arkansas, Delaware, District of Columbia, Kentucky, Louisiana,
Maine, Michigan, New Jersey, New Mexico, New York, North Dakota, Pennsylvania,
South Dakota, Tennessee, Texas, Virginia, Washington and West Virginia
Any person who knowingly and with intent to defraud any insurance company or another person, files a statement of
claim containing any materially false information, or conceals for the purpose of misleading, information concerning
any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and
[NY: substantial] civil penalties. In DC, LA, ME, TN, VA and WA, insurance benefits may also be denied.
Applicable in Nevada
Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false,
incomplete or misleading information concerning a material fact is guilty of a felony.
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Applicable in Minnesota
A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false,
incomplete, or misleading information commits a felony.
Applicable in Indiana
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
Applicable in Hawaii
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides
false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or
attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Applicable in Colorado
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Applicable in Ohio
Applicable in New Hampshire
Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim
containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance
fraud, as provided in RSA 638:20.
WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for
the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Applicable in Oklahoma
Applicable in California
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a
false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state
prison.
For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly
presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Applicable in Arizona
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PROPERTY LOSS NOTICE INSURED AM NOYES PM CONTACT (Crum & Forster Insurance)

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Completed 13 July 2021

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