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First Notice of Loss Form - Property

As of 5/23/2019

YOUR AGENT FOR THIS POLICY
Agent Name:

* denotes required information

Policy Number:

*Loss Reported By:

*Contact Name:

E-Mail Address:

Address:

*Primary Phone:

City:

Secondary Phone:

State:

Zip:

*When did the loss happen?

MM/DD/YYYY format

Where did the loss happen?

Insured Property Address
Other Location

Address	City	State	Zip

What Happened?
(Select all that apply)

*Description of the loss:

250 characters max

Contacts involved in the incident?

Was anyone injured?

Please list any additional insured locations that were affected:

Was a Police Report Filed?

Responding Police department:

Is there standing water
within the Property?

By clicking this check box, you agree to receive an email confirmation of this claim form from Republic Group.

If you experience any issues using this form, or if you wish to speak to a Republic Claim Representative,
call 800-344-2275.