Homeowners Loss Notice Form - Berger & O'Neal Insurance

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

Policyholder Information
Policy Number:
	Check this box if Policyholder Name/Telephone Number matches "Contact Information".
If you checked the box above, please skip to "Accident Information", otherwise complete the questions in this shaded area.
Policyholder Name:
Daytime Phone:
Policyholder - Address:
Address (line 2):
Policyholder - City:
Policyholder - State:	Zip:

Incident / Loss Information
Date of Incident:
Time of Incident:
Description of Incident:
Police/Fire Contacted?:	Yes No
Police/Fire Report Number:
Police/Fire Department Name:
Any Witnesses Present?:	Yes No
Did Injuries Result from Accident?:	Yes No
If there were injuries, please provide Name, Address, Phone Number and Extent of the Injuries in the box below.

Damage Information
Was Your Property Damaged?	Yes No
If your property was damaged, complete the questions in this shaded area.
Describe the Damage to Your Property:

Other Involved Parties

Provide contact information for ALL parties involved in the incident.

Comments or Information

Fraud Warning

Any person who, with the intent to defraud or deceive, submits an
application or files a statement of claim containing any false, incomplete or
misleading information, or helps in any manner to commit a fraud
against an insurer, may be subject to civil penalties and criminal
prosecution for insurance fraud.