Name:

Company:

Address:

Reports to:

Contact preference: Email Telephone Mobile Phone FAX

Email:

Telephone:

FAX:

Mobile Phone:

Name:

Claim number:

Address:

Home telephone:

Work telephone:

Mobile phone:

Date of loss:

Time of loss:
AM PM

Amount of loss (approximate):

Has the loss been investigated by anyone? yes no
If yes, who investigated the loss (include the investigator's phone number)?

Have items been removed from the scene? yes no
If yes, list removed items and the present location:

Where were the policyholder(s) and/or people who lived/worked at the residence/facilities at the time of the incident? yes no

Was anyone injured? yes no
If yes, the extent of injury and their location?

Name the fire departments who responded:

Did they investigate the loss? yes no
If yes, list who, contact phone #, and conclusion:

How badly was the building burned? partial - roof not breached total - roof off, some walls gone gutted - no walls or roof (black hole)

Suspected area of origin:

Note anything that ACE should know prior to our site visit:

Please print a copy of this form for your records. If you have difficulty submitting the form via Email, please display the printable form, then print and fax it separately.