ARM-Capacity of New York ~ Property Loss Notice

HEADQUARTERS
90 Broad Street, Suite 1503
New York, NY 10004
Tel: 646.459.2400
TF: 888.276.6369
Fax: 212.937.3923

Property Loss Notice

The following information is required to submit a property claim. All information must be completed. Should you require assistance to complete this form, please contact your service representative.

Date of Occurence (mm/dd/yyyy)

Time of Occurence
am pm

Date Claim was made (mm/dd/yyyy)

INSURED (how the policy is listed)

Name:

Address:

City State ZIP

CONTACT (insured contact information - i.e. owner, facility manager, etc.)

Name:

Home Phone:

Business Phone:

Cell Phone:

Email:

LOSS

Location of loss:

Police or Fire Dept. which reported:

Kind of loss:

Fire Lightning Flood

Theft Hail Wind

Other (please describe)

Probable amount of entire loss:

Description of Loss and Damage (be specific):

Reported by:

IMPORTANT:
In addition to submitting this form,
you MUST send any and all additional information including:
- Police Reports
- Hospital Reports
- Internal Incident Reports
You may also print and fax this form for processing to:
212.937.3923