Property Loss Report
DATE AND TIME OF LOSS INFORMATION
Alliant Insurance Services
Phone: (415) 403-1400 ext. 445
Fax: (415) 403-1466
E-mail report to [email protected] AND [email protected] With a cc: to [email protected]
McLarens Fax: (949) 757-1692
Date of Report of
Loss Date of Loss
Time of Loss
Previously Reported?
CLAIMS REPORTING
INSURED INFORMATION CONTACT INFORMATION
LOSS DETAILS
Name
Police or Fire Dept to which reported
Theft
Hail/Wind
Boiler & Machinery
Estimated Amount of Total Loss (if known)
Description of Loss and Damage
POLICY INFORMATION
Mortgagee/Loss Payee Yes No
Item No. Subject of Insurance Amount Deductible Coverage Bldg Contents
Other
Bldg Contents
Other
REMARKS/OTHER INSURANCE
Reported by
Yes No
INSURANCE COMPANY AND POLICY INFORMATION
Insurance Company
Policy Number
Effective Date
Address
City State Zip
Email
Phone Fax
Name and Address
PRISM and its
Member Agencies
Member
State Zip
Location of Loss
Address
City
Is this a vacant building? Yes
Kind of Loss:
Fire
Water
Auto
Other
No
Bldg
Other
Contents