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  Chapter Name:
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  phone
  National Fraternity Affiliation:
  Policy Number:
Loss Information
  Date of Loss:
  Time:
  Location:
  Type: (i.e. wind, hail, theft, etc.)
  Description
  Extent of Damage
Contact Information
  Name:
  Title:
  E-mail address:
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  Mortgagee/Loss Payee:
Will this person provide access to the property?
    Yes: No:
If no, please provide a secondary contact to access the property
  Name:
  Title:
  E-mail address:
  Address:
  City:
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  Home Phone:
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Was this reported to:
Police Department: Yes: No:
Fire Department: Yes: No:
 
Name of Investigating Agency and Case #
 
     
  Were emergency repairs required? Yes: No:
If yes, name, provide the contractor information below
  Name of Contractor
  Contact Name
  Work Phone
  Cell Phone
 
Do you have a contractor selected to complete the repairs?
Yes: No:
  Name of Contractor
  Contact Name
  Contact Number
  Estimate Amount:
  Additional Remarks:
  Name of person completing report:
  Date Report Completed
 
 

 

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