NORTH COUNTRY INSURANCE COMPANY

PROPERTY LOSS NOTICE

Date: Date of Loss: Time of Loss Agency: Agency Phone #:	Policy Type: Policy Number: Previously Reported: Yes No


Insured Info	Contact Info
Name: Address: City: State: Zip Residence Phone #: Business Phone #: Cell Phone #: Email Address:	Name: Residence Phone #: Business Phone #: Cell Phone #: Email Address: Where to Contact: When to Contact:
Loss
Police or Fire Department to Which Reported:
Probable Amount of Entire Loss:
Location of Loss (Include City & State):
Description Of Loss:
Remarks:
Reported By:
"Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."
The person completing this Loss Notice hereby affirms that the statements and representations made herein are true to the best of his/her knowledge.