NIC

NATIONAL INSURANCE COMPANY

Loss Report - Property

Notice of Loss

Claimant:
Name:		Last Name:
Social Security:
E-Mail

E-Mail:

Phones
						Unit:

Contact Person:

Best Time To Inspect Damages:
hh:		mm:		am		pm

Physical Address of the Affected Property

Country:

Zip Code:

Postal Address

Country:

Zip Code:

Policy Information
Policy No:			Certificate No.:

Policy Effectivity Date/Expiration Date & Date of Loss (mm/dd/yy)
Effective Date:
Expiration Date:
Date of Loss:

Loss Information
Type of Loss:		Other:		Estimated Damages $:

Police Information
Police Complaint No:

Description of Loss