INSURANCE LOSS NOTICE

INSURANCE LOSS NOTICE - State of West Virginia

Instructions:

For all losses, complete sections 1, 2 & 3
For auto losses -- also section 4
For Insured Property losses -- also section 5

(1) Insured Name:
Insured Acct. #(required)

Insured Address:

Insured Phone Number(day):
Contact Person
Position with insured

Department: (If your department is not listed please select none)

(2) Date of Loss: (MM/DD/YYYY)
Time of Day:

Location of Occurence: (Street Address)

Description of Occurence:

Investigated By: (Police, Fire, etc.)

(3) Injured/Property Damaged
Name (injured/owner)

Home Phone #:

Address:

Work Phone #:

Age: Sex: Male Female N/A

SSN:

Occupation:

Employer:

Where is Property Now?

Description-Injury:

Description-Property Damage:

Estimate Amt. $

Witness:
Comments:

(4) Auto Losses Only

Insured Vehicle

Year	Make	Model
VIN
Vehicle Driver
Vehicle Owner
Passengers
a
Claimant Vehicle
Year	Make	Model
VIN
Vehicle Driver
Vehicle Owner
Passengers
a

Comments:

(5) Insured Property Losses Only: Loss Type -- If other please enter the type of loss in the space provided

Fire	Windstorm	Burglary & Theft	Boiler & Machinery	Fidelity
Vehicle	Aircraft		Other
N/A

Submitted By

West Virginia Board of Risk Insurance Management * 90 MacCorkle Ave., S.W. Suite 203, So. Charleston, WV 25303
(304) 766-2646 * (800) 345-4669 * Fax (304) 744-7120