Claim reporting form - Nacora International Insurance Brokers

Claim reporting form - Nacora International Insurance Brokers

Nacora Insurance Brokers Ltd.
Claim Reporting Form
A: Caller Information
Mr.
Mrs.
Ms.
First Name:
Last Name:
Street address: (include suite or unit number)
Daytime phone:
Evening phone:
City - Province/State - Country - Zip/Postal code
Cell/mobile phone:
Report Date:
B: Policy Information
Policy Number:
Insurance Company:
Coverage:
Expiry Date:
C: Loss Information
Location of Loss
Time of Loss:
Date of Loss:
City - Province/State - Country - Zip/Postal code
D: Description of Loss
Witness 1
Witness 2
Name:
Name:
Address:
Address:
Daytime phone:
Daytime phone:
Evening phone:
Evening phone:
E: Police Information (if applicable)
Officer's Name:
Badge number:
Print your name:
Email your completed form to: [email protected]
Signature:
Detachment/Precinct:
Report date:
Date:
Form Date: May 2014