The Illinois FAIR Plan Association  

Contact Us: mvazquez@illinoisfairplan.com 312.861.0385



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Date of Loss:

mm/dd/yyyy
 

Time of Loss:

HH/MM

 

Policy Number:

Insured Information:

 

Insured Name:

 

Street Address:

 

City:

 State:

Zip Code:

 

Home Phone:

Business Phone:

 

Cell Phone:

Email Address:
 

Spouse Name:

 

Street Address:

 

City:

 State:

 Zip Code:

 

Contact:

 

Name:

 

Street Address:

 

City:

State:

Zip Code:

 

Home Phone:

Business Phone:

 

Cell Phone:

Email Address:
 

Where To Contact:

 

When To Contact:

 

Loss:

 

Loss Address:    Police Report #:

 

City:

State:     Zip Code:

 

Type of Loss:

Fire: Lightning: Flood: Theft: Hail: Wind:

Other (explain):

 

Description of Loss & Damage:
 

Reported By:

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.