Century Insurance Group
Property Loss Notice

Fraud Statement - Applicable in All States:
Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

 

** Required Fields

Agent Information

Name:
 

Phone Number:
 

Address:
 

City 

State: 

Zip:
 

Insured Information

Insured's Name:
  **

Address:
  **

City:

**

State:

**

Zip:
 **

Contact Person:
  **

Address:
  **

City:
 **

State:
 **

Zip:
 **

Primary Phone Number:
  **

When to Contact:
 **

Secondary Phone Number:
 

Where to Contact:
 **

Policy Information

Effective Date: 

**

Expiration Date:
 **

Policy Number:
 **

Claim Information

Date of Loss:
   **

Location of Loss:
 

Authorities Notified:

If Yes, Whom:
 

Description of Loss: 
  **

Kind of Loss:  

Other Kind of Loss:
 

Claimant / Property Damage Information

Name (Injured/Owner):
 

Phone Number:
 

Address: 

City:
 

State:
 

Zip:
 

Age: 

Sex:
 

Occupation:
 

Employer's Name:
 

Phone Number: 
 

Address:
 

City:
 

State:
 

Zip:
 

Describe Injury or Property Damage:
 

Hospital / Where can Property be seen?
 

Remarks
 

Reported By:
  **