Tomei Insurance Agency - Property Loss Notice

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Property Loss Notice

Contact Information

Your Full Name: (as listed on policy now)
Your Email Address:
Daytime Telephone Number:

Description of Loss

Time & Date of Loss:	Time AM PM Date
Location:
Description of Loss:
Police or Fire Department: Notified?	Yes No
If Yes, Please Specify:
Is Property Habitable?:	Yes No
If No, Where Are You Staying: or Planning to Stay?	(Please include Address & Telephone #'s you can be reached at):

Mortgagee or Bank Information

Please Note: Submitting this form via the website does not constitute a "formal" claim. Please contact us or your insurance company to notify of a loss.

Enter the security code you see above. Code is NOT case sensitive.*

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Tomei Insurance Agency, 223 N. Riverside Drive (Rt. 21 @ Wash St.) , Gurnee, IL 60031
Toll Free 877-336-8595, Local 847-336-8595, Fax 847-336-6598, Mail@TomeiInsurance.com, www.TomeiInsurance.com

*Securities offered through Investment Planners Inc.
Member FINRA/SIPC
226 W. Eldorado St.,
Decatur IL 62525
Tomei Insurance Agency is not affiliated with Investment Planners Inc.