EGIS Insurance and Risk Advisors

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INSURED
Name of Insured
Policy Number
Please Select Account Manager
Insured's Mailing Address
Street Address
Address Line 2
City
State
Zip Code
Name of Contact
Contact's Email Address
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact's Mailing Address *
Same as Insured's Mailing Address
Street Address
Address Line 2
City
State
Zip Code
LOSS INFORMATION
Date of Loss

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Time of Loss

AM/PM Option
Location of Loss
Kind of Loss
Description of Loss & Damage
Additional Remarks
Reported By
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Pursuant to S. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive any insurer or insured, prepares, presents, or causes to be presented a proof of loss or estimate of cost or repair of damaged property in support of a claim under an insurance policy knowing that the proof of loss or estimate of claim or repairs contains any false, incomplete, or misleading information concerning any fact or thing material to the claim commits a felony of the third degree, punishable as provided in S. 775.082, S. 775.083, or S. 775.084, Florida Statutes.
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