                             PROPERTY LOSS NOTICE                DATE ________

PRODUCER:  PHONE ___ ___ ____ EXT ____   MISCELLANEOUS INFORMATION: __________
 _____________________________________   _____________________________________
 _____________________________________   COMPANY: ____________________________
 _____________________________________   POLICY NO: __________________________
 _____________________________________   POLICY EFF DATE: ____________________
 _____________________________________   POLICY EXP DATE: ____________________
CODE: __________   SUBCODE: __________   DATE/TIME OF LOSS: __________________

INSURED                                  PREVIOUSLY REPORTED:  ___ YES  ___ NO
NAME AND ADDRESS:                        RES PHONE ___________________________
 _____________________________________   BUS PHONE ___________________________
 _____________________________________   CONTACT: ____________________________
 _____________________________________   WHEN: ____________ WHERE: ___________
 _____________________________________   CONTACT RES PHONE: __________________

LOSS                                     CONTACT BUS PHONE: __________________
LOCATION OF LOSS _____________________   POLICE OR FIRE DEPT TO WHICH REPORTED
 _____________________________________   _____________________________________
KIND OF LOSS _________________________   PROBABLE AMOUNT ENTIRE LOSS _________
DESCRIPTION __________________________________________________________________
 _____________________________________________________________________________

POLICY INFORMATION
MORTGAGEE: ___________________________________________________________________
HOMEOWNER POLICIES SECTION 1 ONLY
COVERAGE A     COVERAGE B     COVERAGE C     COVERAGE D     DESCRIBE ADD COV
 DWELLING      APP STRUCT     PERS PROP      ADD LIVING
 ___________ ______________ ______________ ______________ ____________________
SUBJECT TO FORMS __________________________________________ DEDUCTIBLE _______
FIRE, ALLIED LINES & MULTI-PERIL POLICIES
ITEM   AMOUNT    BLDG   CONTS   OTHER   %COINS   DED   COV AND/OR DESC OF PROP
 __  __________  ____   _____   _____    ____   _____  _______________________
 __  __________  ____   _____   _____    ____   _____  _______________________
 __  __________  ____   _____   _____    ____   _____  _______________________
SUBJECT TO FORMS _____________________________________________________________

MISCELLANEOUS INFORMATION
OTHER INSURANCE ______________________________________________________________
 _____________________________________________________________________________
REMARKS ______________________________________________________________________
 _____________________________________________________________________________
 _____________________________________________________________________________
 _____________________________________________________________________________
ADJUSTER ASSIGNED ____________________________________________________________
REPORTED BY __________________________   REPORTED TO _________________________
PRODUCER'S SIGNATURE ___________________________________________ DATE ________
