Uninsured Property Loss Report (Non-Auto)

Insured's name

Policy number

Phone

Physical address

Mailing Address

E-mail address

Date of loss

Time of loss

Type of loss

Was it reported to the police?

Police complaint number

Police officer's first and last name

Police officer's badge number

Place where the loss occurred

The content of this report does not imply recognition of responsibility of the parties involved in the accident, but a correct compilation of information that will facilitate the processing of claims that may be made as a result of this accident. LAW #18 ARTICLE 27.320 "Any person who knowingly and with intent to defraud files false information in an application for insurance, or who presents, assists or causes to be presented a fraudulent claim for the payment of a loss and other benefit; or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction thereof, shall be sanctioned for each loss, shall incur a felony and, upon conviction thereof, shall be sanctioned for each violation with a fine of not less than five thousand ($5,000) dollars, nor more than ($10,000) dollars or imprisonment for a fixed term of three (3) years, or both penalties. If there are aggravating circumstances, the fixed penalty established may be increased up to a maximum of five (5) years; if there are extenuating circumstances, it may be reduced to a minimum of two (2) years."

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Uninsured Property Loss Report (Non-Auto)

Uninsured Property Loss Report (Non-Auto)

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