Property Loss Notice All fields are required. Policy Number     Person Insured Name     Address     City     State     Phone Number  xxx-xxx-xxxx    Property Loss Information Date of Loss  mm/dd/yyyy     Time of Loss  hh:mm AM/PM      Location of Loss     Cause of Loss   Description of Loss   Estimate of Damage     Temporary repairs necessary? Yes No   Remarks   Person making report (name and phone)

3905 South 148th Street, Suite 100                                              Omaha, NE 68144                                                                                            800-642-8572

© 2010 Cooperative Mutual Insurance Company. All Rights Reserved.
Created in partnership with VistaComm®