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First Notice of Loss Form - Property

As of 9/18/2021
* denotes required information

  Policy Number:        
*Loss Reported By:   

Insured Contact Information

*Contact Name: E-Mail Address:
Address: *Primary Phone:
City: Secondary Phone:

Basic Loss Information

*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) 
Mechanical Breakdown
Other - Not listed above
*Description of the loss:
250 characters max

Contact Information

Contacts involved in the incident?
NamePhone #AddressCityStateZipRole


Was anyone injured?
NamePhone #Describe Injuries

Additional Loss Information

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.