Claims Loss Notice
For assistance call: 678-498-4750 or toll free: 800- 884-1709
Agency Information
Agency #:
000999
Agency Name:
SIU - DO NOT USE!!!
Agency Status:
Active
*
Contact:
*
*
Phone:
(NNN-NNN-NNNN)
*
*
*
Email:
*
*
Policy Information
*
Policy Number:
*
*
Date of Loss:
*
Time of Loss:
*
Insurance Company:
*
*
Policy Effective Date:
*
*
Policy Expiration Date:
*
*
*
Name of Insured:
*
Current Address
*
Address 1:
*
Address 2:
*
City:
*
*
ZipCode:
*
*
State:
*
*
Insured Contact Person:
*
*
Primary Phone No:
*
*
Secondary Phone No:
Email Address:
*
Type of Claim :
Property Loss
General Liability Loss
Automobile Loss
Automobile Loss Information
Year
Make
Model
*
Insured Vehicle Description:
*
Invalid year
*
Insured Vehicle ID Number:
*
*
Driver of Ins.Vehicle:
(Firstname,Lastname)
*
Driver Phone Number:
*
*
Police/Fire Report#:
*
Driver Injured:
Select One
Yes
No
Unknown
Remarks:
*
Number of Claimants:
Select One
0
1
2
3
Unknown
*
Description of Loss :
*
*
Description of Damage/Injury :
*