Fillable PROPERTY LOSS NOTICE INSURED CONTACT CONTACT INSURED AM

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PROPERTY LOSS NOTICE INSURED CONTACT CONTACT INSURED AM

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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
Print Form
ACORD 1 (2006/02)
* In Florida - Third Degree Felony
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.
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 and VA, insurance benefits may also be denied.
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.
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.
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.*
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.
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.
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
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.
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.
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.
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 Arizona
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 and West Virginia
Applicable in California
Applicable in Colorado
Applicable in Florida and Idaho
Applicable in Hawaii
Applicable in Indiana
Applicable in Minnesota
Applicable in Nevada
Applicable in New Hampshire
Applicable in Ohio
Applicable in Oklahoma
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PROPERTY LOSS NOTICE INSURED CONTACT CONTACT INSURED AM

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Completed 6 December 2021

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