Berner and Company, Inc. Insurance

Property Loss Notice

Contact Information

Your Full Name:
(as listed on policy now)

Your Email Address:

Daytime Phone:

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):

Any Additional Information Not Requested Above:

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.

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