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 Business Loss Notice 
Business Loss Notice

Contact Information
Your Full Name:
(as listed on policy now)
Your Email Address:
Daytime Telephone Number:
Description of Loss
Time & Date of Accident/Claim:
Time AM PM
Date
Location:

Type of Accident/Claim:

Property
Liability
Automobile
Workers Comp
Other:

Description of Loss:

Name(s) of Injured Parties:
Vehicle Description:
(applicable to Auto Claims Only)
Driver Name:
(applicable to Auto Claims Only)
Any Additional Information Not Requested Above
Please Note: Insurance coverage cannot be bound without a written binder from our office.

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Personalized Protection since 1951

503 North 7th Street
Fowler, CA 93625
(559)834-5333
Fax(559)834-2626

© C.D. Simonian Insurance Agency, Inc., 2011 
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C. D. Simonian Insurance Agency, Inc. is a BBB Accredited Insurance Company in Fowler, CA