Business Loss Notice Form

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Also see our
claim procedures information and
claim telephone numbers.

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 Gillman Insurance or your insurance company.

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

* All fields required.

Contact Information
Insured Name:
Company:
Address:
Reporter's Name:
City:
State:	Zip:
Home Phone:	Work 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

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