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First Notice of Loss Form - Property

As of 11/15/2018
* denotes required information

  Policy Number:        
*Loss Reported By:   

Insured Contact Information


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

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) 
Fire
Lightning
Wind
Tornado
Water
Theft/Vandalism
Hail
Mechanical Breakdown
Other - Not listed above
*Description of the loss:
250 characters max
 

Contact Information


Contacts involved in the incident?
NamePhone #AddressCityStateZipRole
 

Injuries


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.