claims test | Beacon Club

claims testJenny Nam2022-04-15T02:00:18+00:00

Loss Report

1Loss Report

2Loss Information

3Contact Information

Loss Report

Broker

Broker Email *

Contact Person *

First

Last

Phone

Name of Insured (Full Legal Name) *

First

Last

Policy Number

Mailing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Risk Location Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Loss Information

Date of Loss

Date

Time

Location of Loss

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Description of Loss and Damage

Contact Information

Contact Person/Claimant *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Business Number

Other Number (i.e. Cellular)

Has an independent Adjuster been appointed?

Yes
No