Name of Insurance Company: Policy Number:..........................................

Name of Broker/Agent:...................................

Name of Insured:.........................................

Address of Insured:.......................................

Phone Number:.................................................Email Address:......................................................

Address of Premises where loss occurred:....................................

Date and time of loss:.....................................................

When was loss discovered and by whom? ...................................

Were the premises occupied at time of burglary? .................................................

If not, when where they last occupied? ....................................................................

How were the premises entered and exited by the perpetrators? .........................................................
Which portion of the premises was affected by the burglary? .........................................................

Brief description of property damaged, if any. .....................................................

List of articles stolen and their values at time of loss. ..................................................................
Have the Police been contacted? _............................................_ Policy File Number

I hereby declare that the statements and particulars made herein are true and correct to the best of my knowledge.

Date: ___________________

___________________________

Signature of Insured