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101

 

Business Loss Notice Form



Contact Information
Insured Name:
Company:
Address:
Reporter's Name:
City:   State:   Zip:
Home Phone:   Work Phone:
E-mail Address:

Loss Information
Date of Loss:
Time of Loss:
Location of Accident or Occurrence:
Description of Accident or 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:  

Comments or Information

 
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Berger & O'Neal Insurance Group
10425 Old Alabama Road Connector, Suite 101
Alpharetta, Georgia 30022
770-442-0770 Toll Free 1-866-442-0770 Fax 770-442-0774