Assureguard EVSSL      This Online Application is on a Secure Server. Click on the seal on the left for more information on the certificate's authentication. Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days. Policy Holder Information Name Insured: Address: Phone #: Work     Home Email: Time and Description of Loss Time & Date of Loss Time a.m. p.m. Date Location of Property: Description of Loss: Authority Notification Were the Police or Fire Dept. Called? Yes     No If Yes, which Authority? Property Status Is the Property habitable? Yes     No If No, where are you staying: (Address and Telephone) Report Information Reported by: Date: Signature: ___________________________________________ This Property Loss Report Form Copyright © 1998 - by ENHANCED Web Services