Multinational Personal Insurance Notice and Proof Of Loss
NOTICE OF LOSS
Completion of this form and forwarding any requested documents will expedite the handling of your claims
* indicates required field
I. Preparer Information

Your Name:
Email Address:* (Required in order to send confirmation that your loss has been received.)
Date Prepared:

II. General Information

Insured Individual: Policy Number:
Address: Country:
Business Phone: Fax Number:
Residence Phone: Email Address:
Where to Contact: Home Work Best Local
Time to Call:
Other Contact Instructions:
Insured Employer:

III. Property or Political Risk Information

Date of Loss: Loss Location:
(include Country)
Description
of Loss:
What Police or Other Authority Contacted:
Name of Official Reported To:
What, if any, police action was taken:
(Please forward a copy of any police report for a Property claim or other report in support of a Political Risk claim.)

Schedule of Property Loss

Description of Articles Current Replacement
or Repair Costs
Duties or Taxes* Amount Claimed**
  Local Currency US Dollars    
      Total: US $
* Estimate any duties and taxes payable upon the importation of replacement property into the country where the insured resides
** Please forward any repair bills or purchase receipts.
(If you have additional articles to enter, please utilize the remarks section at the end of this form.)

Would you prefer payment of loss in:  Local Currency US Dollars
 
Transit-additional Information:
Was lost or damaged property in the custody of a steamship, railroad company, airline or other carriers? Yes No
If yes, give name of carrier:   (identify voyage, railroad, or flight #)
Was property shipped under a bill of lading or similar consignment document? Yes No
If yes, forward a copy of the bill of lading or consignment document.
If no report was made against carrier, please explain fully:

IV. Personal or Excess Liability (including neighbors & tenants)

Loss Date: Location of Loss::
(include Country)
Loss Description (including cause):
What Police or other Authority Contacted:
Name of Official Reported to:
What, if any, police action taken by Authorities:
(Please forward a copy of any police or other authority report) 
 
Property Damage (if applicable):
Describe property and extent of damage:
Name and address of owner of property:
Probable amount of loss in local currency:
 
Injured Persons (if applicable)
Name Address Age Extent of Injuries
 
Witnesses or Passengers (if applicable)
Name Address  Telephone Number
 
Insured Vehicle or Watercraft (if applicable)
Year, Make, Model: Country where licensed/registered:
Name of Owner: Owner's Address:
Name of Operator: Address of Operator:
Relationship of driver/watercraft operator to insured: 

V. Other Insurance

Is there other insurance which applies to this loss? Yes No
If there is other insurance, please provide the information below.
Insurance Company & Policy # Policy Period Kind of Coverage Amount of Insurance in Original Currency
 

VI. Remarks


VII. E-Mail Instructions
Once you have completed this Notice of Loss form, press the 'Submit Loss for Review' button at the end of this form. All receipts, police reports, and/or other relevant documents should be faxed without delay using the appropriate fax number shown below. Please retain all originals as they may be requested. 
Fax Numbers:      
From US and Canada: 1-877-200-5202     
From All Other Countries: See Dialing Instructions  


 
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