South & Western General Agency, Inc.

Product & Reporting Information

Product Line

Type of Risk

Type of Loss

Loss Reported By

Your Full Name

Your Phone Number

Your Email Address

Agent Name

Agent Phone

Policy Information

Company/Carrier

Policy Number

Policy Effective Date

Policy Expiration Date

Insured Information

Insured First Name

Insured Last Name

Insured Address

Insured Address (cont)

Insured City

Insured State

Insured Zipcode

Best Time to Contact

Insured Home Phone

Insured Work Phone

Insured Mobile Phone

Insured Date Of Birth

Insured E-Mail

Loss Information

Date of Loss

Police Case #:

Location of Loss is the same as Insured above

Street Address

Street Address (cont)

City

State

Zipcode

Were Police Called?

Police Dept. Name

Was Fire Dept. Called?

Responding Entity

Detailed Description of Loss

Claimant Information

Check this box to enter claimant information.

Claimant First Name

Claimant Last Name

Claimant Address

Claimant Address (cont)

Claimant City

Claimant State

Claimant Zipcode

Best Time To Contact

Claimant Home Phone

Claimant Work Phone

Claimant Mobile Phone

Claimant Date Of Birth

Claimant Email Address

Witness Information

Check this box to enter witness information.

Witness First Name

Witness Last Name

Witness Address

Witness Address (cont)

Witness City

Witness State

Witness Zipcode

Best Time To Contact

Witness Home Phone

Witness Work Phone

Witness Mobile Phone

Witness Email Address

Upon submission (if you provided your email address), you will receive an email confirmation for your records.

I acknowledge the form is completed with all information I currently have available.