Casanueva Insurance

(818) 772 6445

Property Loss Notice

 
Disclaimer:
I understand that this does not constitute an actual claim, but is rather a notification to my agent of an existing loss or claim, and may help expedite the claim process once I have filed.

 

 

 I have read and agree with the above 
(Box must be checked before request can be sent)
 
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:  
City:  
State:  
Zip Code:  
Phone Number:  
Continue>>>

 

 

 
Time and Description of Loss
Time:  
    A.M.  P.M.  
Date:  
Location of Property:  
Description of Loss:  
Continue>>> 

 

 

 

 

 

 

 

 
Authority Notification
Were the Police or Fire Deparment. Called?   Yes  No  
If Yes, Which Authority?  
 
Property Status
Is the Property Habitable?   Yes  No  
If No, where are you staying:
(Address and Telephone)		  
Continue>>> 

 

 

 

 

 

 
Report Information
Reported By:  
Title (if any):  
Date:  
 
Additional Comments
Please give any additional comments you feel appropriate for this Loss Notice.