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Property Loss Claim Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Alternate Phone Number
Optional
E-Mail Address
Required
Policy Number
Required
Loss Overview
Loss Type
Required
What date did the incident take place?
Required
/ /
How severe was the damage?
Required
Describe the Loss
Required
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.







           
717 Manatee Ave W. , Suite 300
Bradenton, FL 34205
Ph: (941) 745-8300
Fx: (941) 745-2571

 
   
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Nicholas Zec, Jr., James E. Boyd, David Grantham, and Kristy Terenzio are Registered Representatives of LaSalle St. Securities LLC, a registered broker/dealer. Securities are offered through LaSalle St. Securities LLC, Member  FINRA/SIPC, 940 N. Industrial Drive, Elmhurst, IL 60126-1131. Boyd Insurance & Investment Services is not affiliated with LaSalle St. Securities LLC. Investing involves risks, including the risk of principal loss.