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.

Henrichs Insurance Services, Inc.

30700 E 1700 North Rd

Saunemin, IL 61769

Phone: 815.689.2315

•

Fax: 815.689.2299

www.henrichsinsurance.com

•

hisc@mchsi.com