Policy Holder

Please be sure to complete all of the requested information so that your agent may contact you after receiving this notification.
Named  Insured::
Street Address:
City, State, Zip
Name of Contact/
Person Filing Claim
Phone Numbers:  Work
Home
E-mail Address:
Fax Number

Details of Claim/Loss
Time & Date of Loss Time AM PM Date
Location:
(Number, Street, Intersection, etc.)
Detailed Description:
(use additional comments below if necessary)
Insured Information:
Mortgagee/Loss Payee (if none, so indicate)
Where can the product be seen?
Estimated $ Amount
of Loss
Where can Damaged Property be seen
Claimant Information Injured
Name:
Address:
City:
State:
Zip:
Home Phone:
Business Phone:
Describe Injury
Witnesses:
Name
Address
City
State
Zip
Phone:
Name
Address
City
State
Zip
Phone:
Remarks:

Additional Information
In the box below, please provide any additional information  you feel may be necessary for this Loss Notice form.

Submission of a loss notice does not represent, assure or guarantee that coverage will be provided by your insurance program.  If information is required, you will be contacted by either a representative of Miller & Associates or your insurance company.

Any person who knowingly, and with the intent to injure, defraud, or deceive a company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony and / or subject to criminal prosecution, civil penalties; punishable by imprisonment or fines.

I have read and agree with the above disclaimer (It is mandatory to check box before request can be sent)