Business Loss Notice Form

Submission of a loss notice does not represent, assure or guarantee that coverage will be provided by your insurance program. If further information is required, you will be contacted by either a representative of Benson Insurance Group or your insurance company.

Please note that this form is for notification purposes only and does not constitute making an actual claim.

Contact Information
Insured Name:
Company:
Address:
Reporter's Name:
City:
State:	Zip:
Business Phone:
E-mail Address:

Loss Information
Date of Loss:
Time of Loss:
Location of Accident/Occurrence:
Description of Accident/Occurrence:
Type of Loss:
If other, please describe:

Property
ESTIMATED LOSS
Property:	$
Real Property:	$
Personal Property:	$
Business Income:	$	No. of Days:

General Liability
INJURED PERSONS
Name (1):		Telephone:
Name (2):		Telephone:
Extent of Injury:
DAMAGED PROPERTY
Owner:		Telephone:
Description:

Additional Comments or Questions

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