Client First Notice of Loss
Please complete as much of this form as you are able.
Person completing this form:
Insured Person or Business:
Policy Number:
Best telephone number to contact:
Type of Claim:
Auto
Home/Condo/Apt
Boat
Business Auto
Business Property
Business Liability
Other
if other please explain
(Worker Compensation claims need to be reported directly to the company)
Date of loss:
May 2012
Sun
Mon
Tue
Wed
Thu
Fri
Sat
18
29
30
1
2
3
4
5
19
6
7
8
9
10
11
12
20
13
14
15
16
17
18
19
21
20
21
22
23
24
25
26
22
27
28
29
30
31
1
2
23
3
4
5
6
7
8
9
Today
Clear
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
OK
Cancel
Where did the loss occur? (Complete Address):
What Happened?:
Names/telephone numbers of witnesses:
Any additional information:
You should receive contact from a company insurance representative within 2 business days of submitting this form. Please call 248-360-4100 if you are not contacted. Completing this form does not confirm coverage. Payment will only be made after the review and acceptance of the insurance company. Do not admit liability, discuss coverages, or policy limits with anyone except the insurance company.
