Property Coverage Claim |

Property Loss Notice Form

After a loss, please report to AMLJIA immediately and work quickly to prevent additional damage. Save all receipts for materials purchased to clean up and perform mitigation repairs. Prior to discarding any contents damaged in this loss, please make a content list of what was thrown away, photograph the item(s), if possible, and ensure the item is not salvageable.

1Member Information

2Loss Information

3Submission

Member Name * Required
Title
Broker Name
Contact Name * Required
First Last
Business Phone * Required
Cell Phone
Fax
Email * Required

Date of Loss - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Time of Loss

: Hours

Minutes

AM/PM AM/PM
Location of Loss
City State
Type of Loss
Cause of Loss
- Fire
- Flood
- Hail
- Lightning
- Theft
- Wind
- Other
If Other, please explain. * Required
Was the loss reported to the Police, State Troopers or Fire Department? * Required
- Yes
- No
If reported, please submit a copy of the report filed for loss.
Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 300 MB.
Maximum file size - 300 mega bytes.
Estimated Cost of Damage
Other Important Information
Additional insurance or remarks regarding this loss.

Printed Name of Person Submitting Form * Required
First Last
Title of Person Submitting Form * Required

Property Loss Notice Form

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Building on Tradition. Protecting Your Future.

Building on Tradition.
Protecting Your Future.