Property Loss NoticeUse Format (123)555-5858Use Format (123)555-5858Use format 1:30am or 11:30pmExample: mm/dd/yyyy(Optional) Item Number(s):
Enter the code shown above:
Phone:Title:Date:Reported By:Current Replacement CostDate Purchased (MM/DD/YYYY)Property ItemList 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: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:Division Code:Department Name:Covered Property:The Phone Call to Risk Management.Forward This Completed Form AFTERTelephone Immediately Upon Discovery.Claim No:(334) 223-6120, FAX (334) 223-6282State of AlabamaFinance DepartmentDivision of Risk Management777 S Lawrence StreetMontgomery, Alabama 36104Agency-Division Code:Property Losses Should be Reported by  Use Format (123)555-5858Agency-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, 4547Fax Number:Email Address:Use Format (123)555-5858