Cooper, Simms, Nelson, & Mosley World Wide Web Site Online Insurance Notification Form
     IMPORTANT NOTICE: Please note that no coverage can be bound using e-Mail, the Internet, or by leaving a voice mail message. All requests must b conducted through our agency with signed applications. 

Toll Free: 1.877.644.2766                                                                                                     Providing Insurance Since 1934

 

 

 
PROPERTY
LOSS NOTICE		   Please use the form below to notify us of any loss or damage to your property insured through this company/agency. Please note that this form is for notification purposes only and does not constitute making an actual claim. One of our representatives will contact you shortly after receiving this notification.
 

 

Disclaimer
I understand that this does not constitute an actual claim, but is rather a notification to my agent of an existing loss or claim, and may help expedite the claim process once I have filed.

 
 I have read and agree with the above disclaimer.
  (Box must be checked before request can be sent)

 

Policy Holder Information
Please be sure to supply your phone number and email address
so that we may contact you after receiving this notification.
Name Insured:
Address:
Phone #: Work      Home
Email:

 

Time and Description of Loss
Time & Date of Loss
Time a.m.
p.m.		     Date
Location of Property:
Description of Loss:

 

Authority Notification
Were the Police or Fire Dept. Called? Yes     No
If Yes, which Authority?

 

Property Status
Is the Property habitable? Yes     No
If No, where are you staying: (Address and Telephone)

 

Report Information
Reported by:
Title (if any):
Date:


Additional Comments
Please give any additional comments you feel appropriate for this Loss Notice.


Please click on the "Submit Form" button to send your Loss Notice.
One of our representatives will respond to your submission as soon as possible.

 

    

 

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