Lappan Agency Inc.
Property Loss Notice
Your Full Name as listed on your Policy:
Please enter your email address:
Daytime Telephone Number:
Time & Date of Loss:
Time:
Select
AM
PM
Date:
Location:
Description of Loss:
Police or Fire Department Notified?
Select
Yes
No
If Yes, Please Specify:
Is Property Habitable?
Select
Yes
No
If No, Where Are You Staying or Planning to Stay?:
(Please include Address & Telephone #'s you can be reached at):
Additional Notes: