First Report of Loss

Insured information

*Named Insured:
Street Address:
*City:
*Province:
Postal Code:
   

Policy Coverage

  
Policy Number:
Policy Term:
Hull Value:

Deductible

  
Not in Motion:
In Motion:
Liability Limits:

Contact Information

  
*Contact's Name:
   
*Please provide Email Address or Day Phone:
   
Email Address:
Daytime Phone:
   
Fax Number:
Home Phone:
Insurance Company:
Date of Report:
Person Making Claim:
Adjuster to Contact:
Adjuster Phone:

Loss Information

  
   
Date of Loss:
Time of Loss:
 
Type of Loss:
    Hull
    Bodily injury
    Property damage
Other Type of Loss:
 
Location of Loss:
Aircraft's Current Location:
Insured Aircraft Involved:
Registration #:
   
Third Party Aircraft Involved:
Registration #:
Pilot's Name:
Pilot's Phone:
   
List claimants/passengers/persons involved and extent of any physical injuries:
   
Claimant 1:
Claimant 2:
Claimant 3:
Claimant 4:
   
Details of Loss:
 
Damage Summary And Any Loss Estimate:


If this form is being filled out by a broker, please fill out the following information.

Name of Brokerage:

Contact:

Phone #:

Email address: