Ogino-Aizumi Insurance Agency - Homeowners Claims

Property Loss Notice NO COVERAGE OF ANY KIND IS BOUND BY SUBMITTING INFORMATION VIA THIS ONLINE FORM. Completion of this form does not constitute an actual claim, but serves to notify your agent of an existing loss or claim. By completing this form, you are acknowledging your understanding of and agreement with these term

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):
Any Additional Information Not Requested Above:

Additional Information Will be Requested Upon Receipt of This Notice.