Property Loss Notice Use Format (123)555-5858 Use Format (123)555-5858 Use format 1:30am or 11:30pm Example: mm/dd/yyyy (Optional)   Item Number(s):
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Phone: Title: Date: Reported By: Current Replacement Cost Date Purchased (MM/DD/YYYY) Property Item List Contents Items Only: Phone Number: Address: Name: If yes, please provide insurance information: Do you have other insurance that would apply to this loss? Other Insurance: Phone Number: Email Address: Name: Contact Person: Estimated Dollar Amount of Loss: $ Nature and Extent of Damage: Police Report Filed? Over $1,000? If Burglary, Evidence of Forcible Entry on Exterior? NOTE: County: Highway: Street: City: . Cause of Loss: Location of Loss: Time: Date of Loss: Loss Information: Building Name: Location Number: Division Code: Department Name: Covered Property: The Phone Call to Risk Management. Forward This Completed Form AFTER Telephone Immediately Upon Discovery. Claim No: (334) 223-6120, FAX (334) 223-6282 State of Alabama Finance Department Division of Risk Management 777 S Lawrence Street Montgomery, Alabama 36104 Agency-Division Code: Property Losses Should be Reported by     Use Format (123)555-5858 Agency-Division Name: Please select from one of the following listings: Example: mm/dd/yyyy *Up to 10 items can be entered. 6 character spaces per item. EXAMPLE: 4545, 4546, 4547 Fax Number: Email Address: Use Format (123)555-5858