A Property Insurance Loss Register

Section 2303 Section 2303.EXHIBIT A   Property Insurance Loss Register ILLINOIS DEPARTMENTAL REGULATIONS COMPLETE WITH AS MUCH FACTUAL INFORMATION AS POSSIBLE AND MAIL IMMEDIATELY AFTER FIRST INSPECTION PROPERTY INSURANCE LOSS REGISTER INSURED (If a business then enter full name of business) 1.  Please type or print. 2.  Use as many forms as necessary. 3.  When more than one form is required then number the pages and staple together. 4.  You MUST keep a copy for your files. PAGE NUMBER name (last, first, middle initial) maiden/also known as age sex 1 spouse (last, first, middle initial) maiden/also known as age sex 2 current address street apt # city state zip 3 previous address street apt # city state zip 4 LOCATION OF LOSS street (print "same" if insured's current address) apt # date of loss mo.  dy.  yr. 5 city state zip time of loss am 6 pm INSURED BY (Repeat ONLY those items involved and omit cents) company policy no. claim no. 7 amount  of  policy building contents stock use & occupancy other 8 total insurance (if more than one policy) 9 replacement cost value 10 actual cash value 11 estimated loss 12 LOSS INFORMATION (Check applicable boxes) known cause of loss was fire dept. report reviewed? 13 type of property dwelling multi-dwelling commercial industrial other (specify) 14 check box if vacant check box if under construction insured's fire losses in last five years:  # type of business (see codes) 15 OTHER PARTIES TO THE LOSS (If a business, then enter full name of business) Enter applicable code   1–Partner, 2–Agent, 3–Attorney, 4–Corporate Officer, 5–Second Mortgages, 6–Public Adjuster, ▼ 7–Contractor, 8–Tenant, 9–Occupant, 10–first Mortgages, 11–Other name (last, first, middle initial) also known as 16 street apt. # city state zip 17 name (last, first, middle initial also known as 18 street apt. # city state zip 19 name (last, first, middle initial) also known as 20 street apt. # city state zip 21 name (last, first, middle initial) also known as 22 street apt. # city state zip 23 ADJUSTER name of staff adjusters company or adjusting firm I certify that I provided the above information and to the best of my knowledge, information and belief, all of such information is accurate. street adjuster's signature date of this report city state zip mo.   dy.   yr. area code telephone number name of adjuster Mail Forms to: P.I.L.R–-700 New Brunswick Avenue Rathway, New Jersey 07065  Tel.  (201)388-5700 check here if this is a supplement (see instructions)