products liability - Property Loss Notice

DISCLAIMER

We are committed to protecting the personal privacy and security of individual consumers who seek or acquire products through one or more of our insurance programs primarily for personal, family, or household purposes ("Consumers"). While information is the cornerstone of our ability to provide you with superior service, we realize that our most important asset is your trust. Therefore, we have implemented strict privacy and security policies on our websites to ensure that no personal identifying information about individual consumers is accessible to the general public. For more details, please review our security statement below.

Depending on the type of insurance program offered to Consumers, your insurance agent/broker may submit personal information about you, others in your household and your vehicles to provide accurate insurance rates to us. This information may be submitted to us electronically via our website. Depending upon your state of residence, this information requested could include: zip code, date of birth, gender, marital status, prior insurance carrier, driving record, vehicle attributes, annual mileage, homeownership and employment. Additional information about you may be submitted to us if you purchase a policy. As permitted by law, we may confirm the information you provide through consumer reporting agencies, publically available records, appraisals or investigatory sources, and/or the Department of Motor Vehicles.

We do not sell any Consumer information to third parties. If you purchase a policy through one of our programs, we may share information about you with the following:

A third party if it is necessary to effect, administer, or enforce your insurance transaction, such as policy processing or claims administration;
Any of our affiliated companies who provide service to you;
Insurance regulatory or government authorities as required by law;
Law enforcement agencies to protect our interest or to report illegal activities;
In response to a valid legal subpoena or court order; and
Persons or organizations conducting actuarial or other statistical studies.


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:
Work Phone Number:
Home Phone Number:
» Email:

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

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)

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

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