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Liability Loss Notice

Liability - Notice of Loss

For use by Insurance Brokers/Advisors Only
Date of Loss*
Time of Loss*

: HH

MM
Policy Number*
Policy Form
Insured Details
Insured Name*
First Name Last Name
Name of Person Reporting*
First Name Last Name
Relationship to Insured*
Insured Telephone*
Cell
Insured Email Address
Insured Address
Street Address Address Line 2 City Province Postal Code
Loss Details
Location of Risk
Location of Loss*
Details of Loss & Remarks &/or Circumstances that may result in a claim*
Brokerage/Agency Details
Brokerage/Agency Name*
Broker/Agent Contact*
First Name Last Name
Broker/Agent Telephone*
Broker/Agent Email