Property Loss Notice Form

Last Report Generated (click to view or download)
 Employer Name
 Location Name
 Department Name
 FROL ID
 Hidden Record ?
 Record Marked for Delete ?

        Basic Case Information
 Report Number
 Date Prepared
 Date Of Loss
 Time Of Loss
 For Information Only
 Claim Status
 Carrier Claim Number
 First Incident Identifier
 Second Incident Identifier

        Agency Information
 Name
 Address 1
 Address 2
 City
 State
 Zip
 Contact
 Contact Phone
 Fax
 Contact Email
 Agency Code
 Agency Subcode
 Customer ID
 Insured Location Code
 Property/Home Carrier Name
 Property/Home Carrier NAICS
 Property/Home Policy Number
 Flood Carrier Name
 Flood Carrier NAICS
 Flood Policy Number
 Wind Carrier Name
 Wind Carrier NAICS
 Wind Policy Number

        Insured Information
 Name
 Date of Birth
 FEIN
 Marital Status
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 Address 1
 Address 2
 City
 State
 Zip
 Primary Email
 Secondary Email
 Spouse Name
 Spouse Date of Birth
 Spouse FEIN
 Spouse Marital Status
 Spouse Primary Phone
 Spouse Primary Phone Type
 Spouse Secondary Phone
 Spouse Secondary Phone Type
 Spouse Address 1
 Spouse Address 2
 Spouse City
 Spouse State
 Spouse Zip
 Spouse Primary Email
 Spouse Secondary Email

        Contact Information
 Contact Insured
 Name
 Primary Phone
 Primary Phone Type
 Secondary Phone
 Secondary Phone Type
 When To Contact
 Address 1
 Address 2
 City
 State
 Zip
 Primary Email
 Secondary Email

        Loss Information
 Address
 City
 State
 Zip
 Country
 Police or Fire Department Contacted
 Police or Fire Department Report Number
 Fire Loss
 Theft Loss
 Lightning Loss
 Hail Loss
 Flood Loss
 Wind Loss
 Other Loss
 Other Loss Description
 Amount Of loss
Description of Loss and Damage (150 characters max)
 Reported By
 Reported To

        Additional Remarks - Sheet 1
Additional Remarks Sheet 1 (Acord 101 Form - 3500 characters max)

        Additional Remarks - Sheet 2
Additional Remarks Sheet 2 (Acord 101 Form - 3500 characters max)

        Identification Code
 Code Description
 Code Value

        User Defined Fields
 User Defined Text 1
 Total Med Cost in $
User Description (100 characters max)
 User Defined Date 1
 User Defined Date 2
User Defined Comment (300 characters max)

        Report History
Report History (click to view or download)


 Release Status
 Release Date
 Release Actions
Release Comments (300 characters max)