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Business Loss Notice Form
 









 

 

 

 

 

 

  

 

Contact Information
Company:
Name:
Address:
City:
State:   Zip:
Daytime Phone: Night Phone:
E-mail Address:

Loss Information
Date of Loss:
Time of Loss:
Location of
Accident/Occurrence:
Description of
Accident/Occurrence:
Type of Loss
(Choose One):
If other, please describe:

Property
ESTIMATED LOSS
Property: $
Real Property: $
Personal Property: $
Business Income: $ No. of Days:

General Liability
INJURED PERSONS  
Name (1):
Telephone:
Name (2):
Telephone:
Extent of Injury:
DAMAGED PROPERTY  
Owner:
Telephone:
Description:

Additional Comments

Submission of a loss notice does not represent, assure or guarantee that coverage will be provided by  your insurance program.   If further information is required, you will be contacted by either a representative of The Zutz Group or your insurance company.

Any person who knowingly, and with the intent to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is:  guilty of a felony and/or subject to criminal prosecution, civil penalties; punishable by imprisonment or fines.

Please click the "Submit Claim" button to send your request.

 

    
 
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The Zutz Group is licensed to provide Property and Casualty Insurance in all states except AK and HI.