• To

    • INSURED INFORMATION

    • CONTACT INFORMATION

    • If Different from Insured
  • OCCURRENCE/CLAIM INFORMATION

  • :
  • INJURED/PROPERTY DAMAGED

  • FIRST WITNESS

  • SECOND WITNESS

  • APPLICABLE IN CALIFORNIA

    For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

    APPLICABLE IN NEVADA

    Pursuant to NRS §686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete, or misleading information concerning a material fact is guilty of a felony.

    APPLICABLE IN WASHINGTON

    It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

    APPLICABLE IN ARIZONA

    For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.