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 Property Loss Notice 
Property Loss Notice

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


Description of Loss:
Police or Fire Department:
Notified?
 Yes No
If Yes, Please Specify:

Is Property Habitable?:
 Yes No
If No, Where Are You Staying:
or Planning to Stay?
(Please include Address &
Telephone #'s you can be reached at):
Mortgagee or Bank Information

Please Note: Submitting this form via the website does not constitute a "formal" claim. Please contact us or your insurance company to notify of a loss.

Enter the security code you see above. Code is NOT case sensitive.*
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 
Hosted By: Insurance Web Designs


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