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> 2004 WKA Golf Outing
Property Loss Form 
Simply complete the form below and click the submit button.
This form can also be printed and faxed to WKA at 860.409.7637 

 

WKA Claim NO. (to be provided by WKA)
Producer (Agent)
Claim NO.
  
First Name
 Last Name
Company
  
Producer Address
Address Line 1
Address Line 2
City
State      Zip   
Full Policy Number
 
Insured
Full Name(s) As Appears On Policy
Property Address
Address Line 1
Address Line 2
City
State      Zip   
Mailing Address (If Different)
Address Line 1
Address Line 2
City
State      Zip   
Where Can Insured Be Contacted?
When?
Policy Dates
 
Full Name(s) As Appears On Policy
Property Address
Address Line 1
Address Line 2
City
State      Zip   
Mailing Address (If Different)
Address Line 1
Address Line 2
City
State      Zip   
Where Can Insured Be Contacted?
When?
 
Loss
Date & Time Of Loss
Loss Location (If Different Than Property Address)
Kind Of Loss
Probable Amount Entire Loss
Description Of Loss & Damage
 
Policy Information

Mortgagee

Fire, Allied Lines & Multi-Peril Policies
* Complete Below Only Items Involved In Loss
Item Amount Bldg. Contents Other % Coins Coverage And/Or Description Of Property Insured

Subject To Form NOS. * insert form nos. & edition dates
Deductible
 
Miscellaneous
Other Insurance
WKA's Remarks
Date
Adjuster Assigned (to be provided by WKA)
Reported By
Reported via Email (enter address)

 

 

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