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This document is a form for reporting property loss exceeding $10,000. It requires details such as the date of loss, type of loss, and estimates for building, contents, and income loss. The form must be submitted with the reporter's contact information.

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dolapo Balogun
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38 views1 page

Form

This document is a form for reporting property loss exceeding $10,000. It requires details such as the date of loss, type of loss, and estimates for building, contents, and income loss. The form must be submitted with the reporter's contact information.

Uploaded by

dolapo Balogun
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FIRST REPORT OF PROPERTY LOSS

(Use this form to report each expected or likely loss of property contents and income in
excess of $10,000)

To:

Date of Loss:

Building Index #: /

Type of Loss: [ ] Fire [ ] Explosion [ ] Lightning [ ] Machinery Breakage.


[ ] Flood [ ] Power Outage [ ] Hail [ ] Outside Theft
[ ] Wind [ ] Inside Theft [ ] Cyber (state type)

Describe Loss:

Estimate of Building Loss $___________________


Estimate of Contents Loss $___________________
Estimate of Income Loss $___________________
Total Estimated Loss $___________________

Submitted by Name:
Date:
Telephone:
Email:

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