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Report Status


Is this the preliminary report or the final report?
Report:
Preliminary Report
Final Report
Adjuster Information


Adjuster's File Number:
Adjuster's Name: *
Telephone: *
Adjusting Firm:
Address:
Community/City:
Province: *
Insured Information


Surname or Company Name: *
First Name:
If applicable
Middle Name:
If applicable
Insured Date of Birth:
If applicable
(MM/DD/YYYY)
Address of the Insured:
Apartment Number:
Community/City:
County:
Postal Code:
Owner Information


Add the information in this section if the owner of the building or vehicle is different from the insured person or company.
Surname or Company Name:
First Name:
If applicable
Other Information


Enter the mortgagee and information on other interested parties including principal owners, partners, company officers, etc.
Mortgagee/Lien Holder:
If applicable
Other Interested Parties:
Fire Information


Date of Loss:
(MM/DD/YYYY)
Time of Loss:
Use 24 hour clock. For example, enter 16:45 for 4:45 PM.
Address of Loss:
Enter the address only if it is different from the address of the insured.
Apartment Number:
Community/City:
County:
Postal Code:
Address Where Fire Originated:
Enter information here only if the address is different from the Address of the Insured or the Address of Loss.
Apartment Number:
Description:
Enter a description of the occupancy and building. For example, residential detached dwelling, apartment residence - 24 unit building, grocery store in shopping plaza or vehicle type and VIN.
Cause of Fire:
If exposure loss, please indicate cause of original fire.
Total Claim


The following sections - building , contents, vehicle and other - are necessary to calculate the total amount of insurance paid on a fire.
Building Insurance Information


Building - Policy Number:
Building - Actual Cash Value:
Do not enter a $ sign or a comma.
Building - Amount of Insurance:
Do not enter a $ sign or a comma.
Building - Reserve:
Do not enter a $ sign or a comma.
Building - Final Amount Paid:
Do not enter a $ sign or a comma.
Contents Insurance Information


Contents - Policy Number:
Contents - Actual Cash Value:
Do not enter a $ sign or a comma.
Contents - Amount of Insurance:
Do not enter a $ sign or a comma.
Contents - Reserve:
Do not enter a $ sign or a comma.
Contents - Final Amount Paid:
Do not enter a $ sign or a comma.
Vehicle Insurance Information


Vehicle - Policy Number:
Vehicle - Actual Cash Value:
Do not enter a $ sign or a comma.
Vehicle - Amount of Insurance:
Do not enter a $ sign or a comma.
Vehicle - Reserve:
Do not enter a $ sign or a comma.
Vehicle - Final Amount Paid:
Do not enter a $ sign or a comma.
Other Insured Items


Other: Policy Number:
Other: Actual Cash Value:
Do not enter a $ sign or a comma.
Other: Amount of Insurance:
Do not enter a $ sign or a comma.
Other: Reserve:
Do not enter a $ sign or a comma.
Other: Final Amount Paid:
Do not enter a $ sign or a comma.
Other Required Information


Fire Dept. in Attendance: *
If no, forward a photocopy of this report to the servicing fire department.
Yes
No
Details of Previous Claims:
Lead Insurance Company:
Insurers:
Indicate number of insurers involved.
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