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Property Claim Form
Property Claim Form
First Notice of Incident Property Loss Information Sheet
Are you insured by Neace Lukens?
*
Yes
No
If yes, list agent name or Neace Lukens office location:
Insurance Company:
*
Policy Number:
*
Date Reported:
*
Insured/Your Company Name:
*
Contact:
Phone:
(Contact)
Reported By:
Phone:
(Reported By)
Check One:
Report as a claim
Report as information only
Was claim called in direct to insurance company
Yes
No
Claim #:
Incident Date/Time:
*
AM
PM
DOT Reportable:
Yes
No
Incident Location:
(Street Address, City, State, County)
*
Characters Remaining: 1000
Incident Description:
(What happened)
*
Characters Remaining: 1000
Location Name:
(if different than insured)
Location Contact:
(to view property)
Phone:
(location contact)
List of Items (Theft or Damage):
(include cost to repair/replace)
Characters Remaining: 1000
Estimated amount of loss:
$
Witness
Witness Name:
Phone:
(Witness)
Police
City/County/State:
Report #:
Phone:
(Police)
*
= required field