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 Property Loss Notice 
Property Loss Notice

Contact Information
Your Full Name:
(as listed on policy now)
Your Email Address:
Daytime Telephone Number:
Description of Loss
Time & Date of Loss:
Time AM PM
Date
Location:


Description of Loss:
Police or Fire Department:
Notified?
Yes No
If Yes, Please Specify:

Is Property Habitable?:
Yes No
If No, Where Are You Staying:
or Planning to Stay?
(Please include Address &
Telephone #'s you can be reached at):
Mortgagee or Bank Information

Please Note: Submitting this form via the website does not constitute a "formal" claim. Please contact us or your insurance company to notify of a loss.

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Insurance Services for Risk and Assets Management
1043 S York Rd LL3, Bensenville IL 60106
©Anna Ruseva - Helpico Insurance Agency












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