ACORD ™ 

PROPERTY LOSS NOTICE
DATE  
PRODUCER
PHONE: (A/C, No, EXT)
CODE:
SUBCODE:
AGENCY CUSTOMER ID:
MISCELLANEOUS INFO (Site & location code)
 DATE OF LOSS AND TIME

AM PM
PREVIOUSLY
REPORTED
YES NO
POLICY TYPE COMPANY AND POLICY NUMBER NAIC CODE POLICY DATES
PROP/ HOME
 CO: EFF:
POL: EXP:
FLOOD
 CO: EFF:
POL: EXP:
WIND
 CO: EFF:
POL: EXP:
INSURED CONTACT      CONTACT INSURED
NAME AND ADDRESS OF INSURED


 DATE OF BIRTH
 NAME AND ADDRESS OF INSURED
SOC SEC # OR FEIN:
RESIDENCE PHONE (A/C, No)
 BUSINESS PHONE (A/C, No, Ext)
NAME AND ADDRESS OF SPOUSE (IF APPLICABLE)


 DATE OF BIRTH
 RESIDENCE PHONE (A/C, No)
 BUSINESS PHONE (A/C, No, Ext)
SOC SEC # OR FEIN:
 WHERE TO CONTACT
 WHEN TO CONTACT
LOSS
LOCATION OF LOSS

 POLICE OR FIRE DEPT TO WHICH REPORTED
KIND OF LOSS
FIRE
THEFT		 LIGHTNING
HAIL		 FLOOD
WIND		 OTHER (explain)
PROBABLE AMOUNT ENTIRE LOSS
DESCRIPTION OF LOSS & DAMAGE
POLICY INFORMATION
MORTGAGEE
NO MORTGAGEE
HOMEOWNER POLICIES SECTION 1 ONLY (Complete for coverages A, B, C, D & additional coverages. For Homeowners Section II Liability Losses, use ACORD 3.)
A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY D. LOSS OF USE DEDUCTIBLES
DESCRIBE ADDITIONAL COVERAGES PROVIDED
COVERAGE A. EXCLUDES WIND
SUBJECT TO FORMS (Insert form numbers and edition dates, special deductibles)
FIRE, ALLIED LINES & MULTI-PERIL POLICIES (Complete only those items involved in loss)
ITEM SUBJECT OF INSURANCE AMOUNT % COINS DEDUCTIBLE COVERAGE AND/OR DESCRIPTION OF PROPERTY INSURED
BLDG CNTS
BLDG CNTS
BLDG CNTS
SUBJECT TO FORMS
(Insert form numbers and edition dates, special deductibles)
FLOOD
POLICY		 BUILDING: DEDUCTIBLE: ZONE PRE FIRM DIFF IN ELEV
 FORM
TYPE		 GENERAL CONDO
CONTENTS: DEDUCTIBLE:   POST FIRM DWELLING
WIND
POLICY		 BUILDING: DEDUCTIBLE: ZONE FORM
TYPE		 GENERAL CONDO
CONTENTS:     DWELLING
REMARKS/OTHER INSURANCE
(List companies, policy numbers, coverages & policy amounts ) / NY ONLY: PREVIOUS ADDRESS OF INSURED & WIFE'S MAIDEN NAME
CAT #
FICO #
 ADJUSTER ASSIGNED
 ADJUSTER #
 DATE ASSIGNED
REPORTED BY
 REPORTED TO
 SIGNATURE OF INSURED
 SIGNATURE OF PRODUCER
Applicable in Arizona
For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Applicable in Arkansas, District of Columbia, Kentucky, Louisiana, Maine, Michigan, New Jersey, New Mexico, New York, Pennsylvania, Tennessee and Virginia
Any person who knowingly and with intent to defraud any insurance company or another person, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and [NY: substantial] civil penalties. In DC, LA, ME, TN and VA, insurance benefits may also be denied.

Applicable in California
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Applicable in Colorado
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Applicable in Florida and Idaho
Any person who Knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim Containing any False, Incomplete or Misleading information is Guilty of a Felony.*
* In Florida - Third Degree Felony

Applicable in Hawaii
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Applicable in Indiana
A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

Applicable in Minnesota
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

Applicable in Nevada
Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.

Applicable in New Hampshire
containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

Applicable in Ohio
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Applicable in Oklahoma
WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
ACORD 1 (2002/01)