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. 1 Member Information2 Loss Information3 Submission Member Name * RequiredTitleBroker NameContact Name * Required First Last Business Phone * RequiredCell PhoneFaxEmail * Required Date of Loss - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY Time of Loss : HH MM AM/PM AM PM Location of Loss City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Type of LossCause of Loss Fire Flood Hail Lightning Theft Wind Other If Other, please explain. * RequiredWas the loss reported to the Police, State Troopers or Fire Department? * RequiredYesNoIf reported, please submit a copy of the report filed for loss.Accepted file types: jpg, png, pdf, doc, docx.Maximum file size - 300 mega bytes. Estimated Cost of DamageOther Important InformationAdditional insurance or remarks regarding this loss. Printed Name of Person Submitting Form * Required First Last Title of Person Submitting Form * Required
