Notice of Business/Worker Compensation Loss

Name of Insured

*First

*Last

*Address

*City

*State

*Zip Code

*Daytime Phone

Business Phone

*E-mail Address

Policy Number (if available)

Date of Accident/Loss

Location of Accident/Loss

Cause of Loss

Describe if "Other" cause:

Temporary shelter required? Yes No

Windows require board up? Yes No

Name of Injured #1

Phone of Injured #1

Describe Injuries (if any)

Describe Cause of Injuries (if any)

Name of Injured #2

Phone of Injured #2

Describe Injuries (if any)

Describe Cause of Injuries (if any)

Additional Comments

* Required information. Please note that insurance coverage cannot be bound without a written binder from our office.