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Date of Loss:

Time of Loss:

Policy Number (if known):

Name of Policyholder:

(Type "unknown" if you do not know your policy number)

Street:

City:

State:

Property Location/Location of Loss:

Description of Loss:

Description of Damage:

Name of Person Making Report:

If not the policyholder, relationship of person making the report to the policyholder:

Home Phone:

Cell Phone:

Business Phone:

E-mail:

Comments (Additional Information):

Pennsylvania: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties."

New York: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."