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Date of Loss:
mm/dd/yyyy
Time of Loss:
HH:MM (AM or PM)
Policy Number:
Insured Name:
Spouse Name:
Street Address:
City:
State:
Zip Code:
Home Phone:
Business Phone:
Cell Phone:
Email Address:
Name:
Location: (Same as insured's address)
Loss Address: Police Report #:
State: Zip Code:
Type of Loss:
Fire : Lightning : Water Damage : Theft : Hail : Wind : Vehicle Damage : Vandalism : Other :
Description of Loss & Damage:
Reported By Email:
(Required)
Reported Time:
DISCLAIMER: Your submission does not commit the Illinois FAIR Plan to coverage for this loss. Information you submit regarding your insurance policy and the loss is subject to our review and verification. We reserve the right to request additional information prior to reaching a decision on the claim. A claim representative will be communicating with you regarding your claim. All policy provisions contained in your policy remain in effect. If you have any questions concerning the coverage afforded by your policy, please contact your agent or the Illinois FAIR Plan Association.
