DATE (MM/DD/YYYY)
PHONE PREVIOUSLY
AGENCY MISCELLANEOUS INFO (Site & location code) DATE OF LOSS AND TIME
(A/C, No, Ext): REPORTED
POLICY
COMPANY AND POLICY NUMBER NAIC CODE POLICY DATES
TYPE
CO: EFF:
PROP/
HOME
POL: EXP:
FAX
CO: EFF:
(A/C, No):
FLOOD
E-MAIL
POL: EXP:
ADDRESS:
CODE: SUB CODE: CO: EFF:
WIND
AGENCY CUSTOMER ID:
POL: EXP:
NAME AND ADDRESS OF INSURED DATE OF BIRTH NAME AND ADDRESS
SOC SEC # OR FEIN:
RESIDENCE PHONE (A/C, No) BUSINESS PHONE (A/C, No, Ext)
RESIDENCE PHONE (A/C, No) BUSINESS PHONE (A/C, No, Ext)
CELL PHONE (A/C, No)
E-MAIL ADDRESS
CELL PHONE (A/C, No) E-MAIL ADDRESS
NAME AND ADDRESS OF SPOUSE (IF APPLICABLE)
DATE OF BIRTH
SOC SEC # OR FEIN: WHERE TO CONTACT WHEN TO CONTACT
POLICE OR FIRE DEPT TO WHICH REPORTED
LOCATION
OF LOSS
PROBABLE AMOUNT ENTIRE LOSS
KIND
OF LOSS
DESCRIPTION OF LOSS & DAMAGE (Use separate sheet, if necessary)
MORTGAGEE
HOMEOWNER POLICIES SECTION 1 ONLY (Complete for coverages A, B, C, D & additional coverages. For Homeowners Section II Liability Losses, use ACORD 3.)
A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY D. LOSS OF USE DEDUCTIBLES DESCRIBE ADDITIONAL COVERAGES PROVIDED
SUBJECT TO FORMS (Insert form numbers
and edition dates, special deductibles)
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
SUBJECT TO FORMS
(Insert form numbers
and edition dates,
special deductibles)
ZONE DIFF IN ELEV
BUILDING: DEDUCTIBLE:
FLOOD FORM
POLICY TYPE
CONTENTS: DEDUCTIBLE:
BUILDING DEDUCTIBLE CONTENTS ZONE
WIND FORM
POLICY TYPE
REMARKS/OTHER INSURANCE (List companies, policy numbers, coverages & policy amounts)/NY ONLY: PREVIOUS ADDRESS OF INSURED & WIFE’S MAIDEN NAME
CAT # FICO # ADJUSTER # DATE ASSIGNED
ADJUSTER
ASSIGNED
REPORTED BY REPORTED TO SIGNATURE OF INSURED SIGNATURE OF PRODUCER
AM
PM YES NO
CONTACT INSURED
OTHER
FIRE LIGHTNING FLOOD
(explain)
THEFT HAIL WIND
NO MORTGAGEE
ON
COVERAGE A. EXCLUDES WIND
BLDG CNTS
BLDG CNTS
BLDG CNTS
PRE FIRM GENERAL CONDO
POST FIRM DWELLING
GENERAL CONDO
DWELLING
INSURED CONTACT
LOSS
POLICY INFORMATION
NOTE: IMPORTANT STATE INFORMATION ON REVERSE SIDEACORD 1 (2006/02) © ACORD CORPORATION 1988-2006
PROPERTY LOSS NOTICE
