Submit a First Notice of Loss
† Indicates a field is required when creating a claim.
* Indicates a field is required when creating a first notice of loss.
Policy Information
Policy Number †
Property Location Address †*
Unit/Apt/Ste
City †*
State †*
FL
Zip Code †*
Claimant Information
Who is reporting this claim? †*
Select One
Insured
2nd Insured
Spouse
Family Member
Attorney
Public Adjuster
Contractor
Other
First Name †*
Last Name †*
How would you like to be contacted? †*
Home
Work
Cell
Email
Phone Type †*
Home
Work
Cell
Phone Number †*
Extension
Email
Insured Information
First Name †*
Last Name †*
How would the insured like to be contacted? †*
Home
Work
Cell
Email
Phone Type †*
Home
Work
Cell
Phone Number †*
Extension
Email
Loss Information
Is this a catastrophic event? †
Yes
No
Catastrophe †
Select One
-- N/A --
Do you know if there is damage to the home? †
Yes
No
Is home livable? †
Yes
No
Is there damage to your roof? †
Yes
No
Are you putting in a claim for a FEMA letter only? †
Yes
No
Is there any damage to the interior of your home? †
Yes
No
Is there any damage to other structures on your property? †
Yes
No
Are you putting in a claim for food spoilage or living expense reimbursement only? †
Yes
No
Is there water coming into your home? †
Yes
No
Are there any other areas or items damaged aside from the roof? †
Yes
No
Do you see areas of the roof missing? †
Yes
No
Is there heavy or minor interior damage? †
Select One
Heavy
Minor
Date of Loss †*
Cause of Loss †*
Select One
Additional Living Expense
Aircraft
Bodily Injury
Care, Custody, Control PD
Collapse
Debris Removal
Discharge Water/Steam
Earthquake
Electrical Current
Environmental (Oil Spills)
Explosion
Falling Object
Fire
Fire Department Service Charge
Fire Legal Liability
Flood
Freezing
Glass Breakage
Hail
Hurricane
Medical Payments
Misc Weather/Natural Elements
Miscellaneous All Risk
Miscellaneous Named Peril
Mold
Partial Conversion - VSI
PE Theft/Burglary off Premises
PE Theft/Burglary on Premises
Property Damage
Lightning
Repossession Return Expense
Riot or Civil Commotion
Smoke
Total Loss Fire
Terrorism
Theft or Attempted Theft
Tornado
Trip Collisions
Total Conversion - VSI
V&MM
Vehicle Damage
VSI Collision
Weight of Ice & Snow
Windstorm
Description of Loss †*
Additional Information
FNOL Status Information
FNOL Status †
Open
Converted
Closed - Damage Under Deductible
Closed - Duplicate
Closed - Lack of Interest
Closed - Other Insurance
Closed - Withdrawn