Homeowners Loss Notice Form

Home :: About Gillman :: Customer Service :: Homeowners Loss Notice Form

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
Full Name:
Address:
City:
State:	Zip:
Daytime Phone:	Night Phone:
Fax:
Best Time To Call:	AM PM
E-mail Address:

Policyholder Information
Policy Number:
Check this box if Policyholder Name/Telephone Number matches "Contact Information".
If you checked the box above, please skip to "Accident Information", otherwise complete the questions in this shaded area.
Policyholder Name:
Daytime Phone:
Policyholder - Address:
Address (line 2):
Policyholder - City:
Policyholder - State:	Zip:

Incident / Loss Information
Date of Incident:
Time of Incident:
Description of Incident:
Police/Fire Contacted?	Yes No
Police/Fire Report Number:
Police/Fire Department Name:
Any Witnesses Present?	Yes No
Did Injuries Result from Accident?	Yes No
If there were injuries, please provide Name, Address, Phone Number and Extent of the Injuries in the box below.

Damage Information
Was Your Property Damaged?	Yes No
If your property was damaged, please describe below..
Describe the Damage to Your Property:

Other Involved Parties

Provide contact information for ALL parties involved in the incident.

Additional Comments or Questions

Legal & Privacy Statement
Copyright © , Gillman Insurance Group, Inc., Alpharetta, Georgia
Insurance Web Design : www.insWebsites.com