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Erwin Insurance Agency

Notice of Loss

First Name *

Middle Name

Last Name *

Phone number *

Are you the named insured on the policy? *

Yes

No

Policy Number

Contact (if different from above)

First Name *

Middle Name

Last Name *

Phone number *

Location of Loss

*

Home	Other property

Street Address *

Address Line 2

City *

State *

Zip Code *

Description of Loss

Loss type (choose all that apply) *

Fire

Theft

Lightning

Water Damage

Wind

Hail

Fire Damage

What was damaged? *

Where does it seem like the fire started? *

Theft

To the best of your ability, describe what happened. *

Please list all that was stolen *

Lightning Damage

Where did the lightning strike? *

What was damaged? *

Water Damage

Did water come into property? *

Yes

No

Where did it come from? *

Lake, Ocean, River, or other body of water

Pipe, sewage, or other internal source of water

Rain

How did it enter the home? *

Wind Damage

What was damaged? *

Hail Damage

What was damaged? *

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