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Insured Name *

Insured Address *

City *

Zip Code *

Best Contact Number *

Policy ID

Date of Loss *

Time of Loss *

Location of Loss *

Describe the Loss *

Detail of Items Damaged or Lost

Relation to Insured

Name of Person Reporting Claim if Other than Insured

Telephone Number of Person Reporting Claim

Disclaimer: This claim will be reviewed and contact will be made as soon as possible following the receipt of this notice. We may not receive this claim promptly if the report is being completed after hours or on weekends or holidays. This reporting capability is soley for the convenience of filing a claim after hours, on weekends or when it is not feasible to contact your agent during normal business hours.

I hereby certify that I have the authority to make this request by being the insured or a representative of the insured.

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