Property, Liability, or Automobile Loss Notice

*Member Community/District:

*Member contact person:

*Member contact e-mail address:

*Contact phone number (area code first):

*Date of incident:

Description of Incident:

Please do not include sensitive subscriber information, such as Social Security Numbers in this form. This form can be viewed by a third party while in transit.

Location of incident:

Full name of person presenting claim:

Claimant phone number (area code first):

Claimant address (line 1):

Address (line 2):

Claimant city:

Type of vehicle involved (if applicable):

Community/District department involved:

General comments:

Please do not include sensitive subscriber information, such as Social Security Numbers in this form. This form can be viewed by a third party while in transit.