McMartin, Wasek & Associates, Inc. - Adjustment Services for the Millennium

10370 Citation Drive, Suite 100

Brighton, MI 48116

Phone:  866-937-7009

Fax:     (989) 229-8039

P.O. Box 888364

Grand Rapids, MI 49588

Phone:  866-937-7008

Fax:     (989) 893-0208

Please complete the following form. When finished, print this page for your records.
(Required fields are marked with a *.)
Property Loss Notice
Date *
AGENT * Address *
Phone * City / State *
Fax * Zip *
COMPANY * Address *
Adjuster * City / State *
Company Phone * Zip *
Company Fax *
Policy # * Policy Eff. Date *
Claim # * Policy Exp. Date *
Date & Time of Loss *
Previously Reported * Yes No

 

Insured
First Name * Insured's Residence Phone
Last Name * Insured's Business Phone
Address * Person to Contact
Address (second line) Where to Contact
City * When to Contact
State* Contact's Residence Phone *
Zip * Contact's Business Phone *
Fax

 

Loss
Location of Loss Police or Fire Department to Which Reported
Type of Loss Probable Amount of Entire Loss
Description of Loss & Damage
Reported By Reported To

 

Policy Information
Mortgagee or Loss Payees (If none so indicated)
Homeowner Policies
Coverage A Coverage B Coverage C Coverage D Describe Additional Coverages Provided
Dwelling Appurtenant
Private
Structures		 Unscheduled
Personal
Property		 Additional
Living
Expenses
$ $ $ $ Deductibles:
Subject to Forms. (Insert form nos. & edition dates, special deductibles)

Commercial Policies

Item # Building Contents BI & Extra Exp. Other R/C (Y/N) Co-Ins Deductible
$ $ $ $ % $
$ $ $ $ % $
$ $ $ $ % $
Subject to Forms. (Insert form nos. & edition dates, special deductibles)


Mortgage / Loss Payees

 

Miscellaneous Information
Other Insurance (List Companies, policy numbers, coverages & policy amounts)


Remarks
Date Assigned
Submitted By Title