Mid States Insurance, Inc. - Business Loss Notice

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Business Loss Notice

Contact Information

Your Full Name: (as listed on policy now)
Your Email Address:
Daytime Telephone Number:

Description of Loss

Time & Date of Accident/Claim:	Time AM PM Date
Location:
Type of Accident/Claim:	Property Liability Automobile Workers Comp Other:
Description of Loss:
Name(s) of Injured Parties:
Vehicle Description: (applicable to Auto Claims Only)
Driver Name: (applicable to Auto Claims Only)

Any Additional Information Not Requested Above


Please Note: Insurance coverage cannot be bound without a written binder from our office.