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Business Loss Notice Form

Submission of a loss notice does not represent, assure or guarantee that coverage will be provided by your insurance program. If further information is required, you will be contacted by either a representative of FNBIA or your insurance company.

Please note that this form is for notification purposes only and does not constitute making an actual claim.

Contact Information
Insured Name:
Company:
Address:
Reporter's Name:
City:
State:     Zip:
Business Phone:   
E-mail Address:

Loss Information
Date of Loss:
Time of Loss:
Location of Accident/Occurrence:
Description of Accident/Occurrence:
Type of Loss:
If other, please describe:

Property
ESTIMATED LOSS
Property: $
Real Property: $
Personal Property: $
Business Income: $ No. of Days:

General Liability
INJURED PERSONS
Name (1): Telephone:
Name (2): Telephone:
Extent of Injury:
DAMAGED PROPERTY
Owner: Telephone:
Description:

Additional Comments or Questions