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Vacant Express

Property Loss Notice

HomeProperty Loss Notice

Insurance Products
For Agents
Policyholders
- Find Your Local Agent
File a Claim
MAKE A PAYMENT
AGENT SIGN IN

1Named Insured

2Contact

3Loss

4Final Remarks

Step 1: Named Insured

I am the*

Agency

Named Insured*

Policy Number*

Mailing Address

City

State

ZIP Code

Primary Phone Number*

Phone Type*

Home

Bus.

Cell

Secondary Phone Number

Secondary Phone Type

Home

Bus.

Cell

Email*

* indicates required field

Same Name

Contact Info is the same as Named Insured

Name of Contact (First, Middle, Last)

Primary Phone Number

Primary Phone Type

Home

Bus.

Cell

Secondary Phone Number

Secondary Phone Type

Home

Bus.

Cell

Contact's Mailing Address

City

State

ZIP Code

Email

When to Contact

Location of Loss Address*

City*

State*

ZIP Code*

Date of Loss*

DD dash MM dash YYYY

Time of Loss

Time of Day

AM

PM

Type of Loss

If Other, please specify

Description of Loss & Damage*

Previously Reported

Yes

No

* indicates required field

Remarks/Other Insurance (list companies, policy numbers and coverages)

Reported By

Reported To

Disclaimer*

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

By checking this box, I acknowledge that I have read and understand the above disclaimer.

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EEO
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Contact Us

610-664-1500
info@global-indemnity.com

© 2021 J.H. Ferguson & Associates, LLC. All rights reserved.
A member of Global Indemnity