Property Loss Notice

Please use the form below to notify us of any loss or damage to your property insured through this company/agency. Please note that this form is for notification purposes only and does not constitute making an actual claim. One of our representatives will contact you shortly after receiving this notification.

» Required Fields


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.

Gutierrez Insurance Solutions, Inc.

4801 S University Dr. Suite 111

Davie
, FL 33328

Phone: 954-454-4779

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Fax: 954-404-7355

www.gisagency.com

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insureme@gisagency.com

DISCLAIMER:

CONFIDENTIALITY NOTICE: Gutierrez Insurance Solutions, Inc. would like you to know that the information contained in this communication, including attachments is privileged and confidential. It is intended only for the exclusive use of the addressee. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. Insurance coverage can not be bound, amended or changed via an e-mail message without knowledge or consent from the insuring carrier. If you have received this communication in error please notify us by telephone immediately at (954)454-4779