COMPLETE WITH AS MUCH FACTUAL INFORMATION AS POSSIBLE AND MAIL IMMEDIATELY AFTER FIRST INSPECTION

PROPERTY INSURANCE

LOSS REGISTER

INSURED (If a business then enter full name of business)

1.  Please type or print.

2.  Use as many forms as necessary.

3.  When more than one form is required then number the pages and staple together.

4.  You MUST keep a copy for your files.

PAGE

NUMBER

name (last, first, middle initial)

maiden/also known as

age

sex

1

spouse (last, first, middle initial)

maiden/also known as

age

sex

2

current

address

street

apt #

city

state

zip

3

previous

address

street

apt #

city

state

zip

4

LOCATION OF LOSS

street (print "same" if insured's current address)

apt #

date

of loss

mo.  dy.  yr.

5

city

state

zip

time of loss

am

6

pm

INSURED BY          (Repeat ONLY those items involved and omit cents)

company

policy no.

claim no.

7

amount  of  policy

building

contents

stock

use & occupancy

other

8

total insurance (if more than one policy)

9

replacement cost value

10

actual cash value

11

estimated loss

12

LOSS INFORMATION        (Check applicable boxes)

known cause of loss

was fire dept. report reviewed?

13

type of

property

dwelling

multi-dwelling

commercial

industrial

other (specify)

14

check box if vacant

check box if under construction

insured's fire losses in last five years:  #

type of business

(see codes)

15

OTHER PARTIES TO THE LOSS (If a business, then enter full name of business)

Enter applicable code   1–Partner, 2–Agent, 3–Attorney, 4–Corporate Officer, 5–Second Mortgages, 6–Public Adjuster,

▼

7–Contractor, 8–Tenant, 9–Occupant, 10–first Mortgages, 11–Other

name (last, first, middle initial)

also known as

16

street

apt. #

city

state

zip

17

name (last, first, middle initial

also known as

18

street

apt. #

city

state

zip

19

name (last, first, middle initial)

also known as

20

street

apt. #

city

state

zip

21

name (last, first, middle initial)

also known as

22

street

apt. #

city

state

zip

23

ADJUSTER

name of staff adjusters company or adjusting firm

I certify that I provided the above information and to the best of my knowledge, information and belief, all of such information is accurate.

street

adjuster's signature

date of this report

city

state

zip

mo.   dy.   yr.

area

code

telephone number

name of adjuster

Mail Forms to: P.I.L.R–-700 New Brunswick Avenue

Rathway, New Jersey 07065  Tel.  (201)388-5700

check here if this is a supplement       

(see instructions)