Kite Insurance Agency LLC

PROPERTY LOSS NOTICE

POLICY HOLDER INFORMATION
Please be sure to supply all if your contact information so we may promptly contact you after receiving this notification.
Name Insured:
Address:
Phone #:	Work Home
Email:

TIME AND DESCRIPTION OF LOSS

Time & Date of Loss

Time

a.m.
p.m.

Date

Location of Property:

Description of Loss:

AUTHORITY NOTIFICATION
Were the Police or Fire Dept. Called?	Yes No
If Yes, which Authority?

PROPERTY STATUS
Is the Property habitable?	Yes No
If No, where are you staying, so we may contact you	(Address and Telephone)

REPORT INFORMATION
Reported by:
Title (if any):
Date:

ADDITIONAL COMMENTS

Please provide and additional comments you feel appropriate for this Loss Notice.

DISCLAIMER:

I understand that by completing this form it does not constitute an actual
claim, but is rather a notification to my agent of an existing loss or claim,
and may help expedite the claim process once I have filed.

One of our representatives will respond to your submission as soon as possible.

Property Policy Change Request

POLICY HOLDER INFORMATION
Name Insured:
Phone #:	E-Mail:
Effective Date of Change:

PLEASE CHECK NATURE OF CHANGE:

Add/Delete from schedule
Add endorsement
Mortgagee Change
Change of mailing address/phone number
Increase/Decrease Limit of Insurance
Other

PLEASE DESCRIBE SPECIFICS OF YOUR REQUEST:

I understand that my coverage (or changes in coverage) ARE NOT binding via this
online request; Changes ARE ONLY considered binding when I receive an email
(or fax) response from my agent indicating that they have received my request.

One of our representatives will respond as soon as possible.