LOSS REPORTING FORM



Loss Reporting FormMUNICIPAL PROPERTY INSURANCE COMPANY9701 Brader Way, Suite 301Middleton, WI 53562Contact: Jerry ParkerPhone: (877) 278-4165FAX: (612) 766-3099Email: claims@ Instructions:Complete this form online or email or mail to MPIC. If available, attach a copy of the police report. This form may be reproduced.Major losses should be reported by phone. Call MPIC at:Phone:(877) 278-4165Complete this section:Policy Number: FORMTEXT ?????Name as it Appears on Policy: FORMTEXT ?????Contact Person (for this claim): FORMTEXT ?????Phone Number: FORMTEXT ?????Fax Number: FORMTEXT ?????Email Address: FORMTEXT ?????WIAddress: FORMTEXT ?????City: FORMTEXT ?????State:Zip Code: FORMTEXT ?????Date of Loss (if unsure, use date discovered): FORMTEXT ?????Time of Loss: Estimated Amount of Loss (attach copy of estimate if available): FORMTEXT ?????Kind of Loss (check one): FORMCHECKBOX Fire FORMCHECKBOX Lightning FORMCHECKBOX Wind FORMCHECKBOX Hail FORMCHECKBOX Glass Breakage FORMCHECKBOX Vandalism (Other than Glass) FORMCHECKBOX Water Damage FORMCHECKBOX Damage by Vehicle FORMCHECKBOX Collision – Vehicle FORMCHECKBOX Comprehensive – Vehicle FORMCHECKBOX Other – Describe FORMTEXT ?????Type of Property: FORMCHECKBOX Building FORMCHECKBOX Property in FORMCHECKBOX Contentsthe Open FORMCHECKBOX Contractors FORMCHECKBOX Money Equipment FORMCHECKBOX Vehicle FORMCHECKBOX Other – Describe FORMTEXT ?????Location of Loss: FORMTEXT ?????Description of Loss and Damage: FORMTEXT ?????Remarks: FORMTEXT ?????Print Name: FORMTEXT ?????Title: FORMTEXT ?????Signature:Date: FORMTEXT ????? ................
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