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Avis de perte responsabilité

Liability - Notice of Loss

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

: Heures

Minutes

AM/PM
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
Adresse postale Adresse ligne 2 Ville Province Code postal
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

Head Office: Vancouver, BC
Toronto, ON
T: 604-669-5211 Siège social : Vancouver, CB
T: 450-497-0016 Laval, QC
T: 604-669-5211 Calgary, AB
T: 416-365-0444 Toronto, ON
T: 519-850-1610 London, ON
T: 855-761-8788Sans frais