Property Loss

General Instructions

When submitting a report, please complete the entire Web Loss Report Form and provide all required information. Required fields are marked in bold.

  • You can open/close any section of this form at any time by clicking a gray section header below.
  • If the mandatory information is unknown at the time of your web submission, enter “unavailable” in any field requiring text. Enter only numerals(1,2,3, etc) in all fields that require a number value.
  • The final report will depend on the accuracy and completeness of the information you are able to provide.
  • No information will be transmitted until you click the “submit” button at the bottom of the form.
  • The Accident Description field will have a 200-character limitation. Additional information can be entered in the final remarks area of the submission. Additional Remarks will have a 200-character limitation.

Emergencies

If your loss is severe, RISCOM recommends that you phone in your loss to 318-698-6600 or after hours to 318-286-8705 to insure that it receives the immediate attention it needs.

General Information >>
1. Date & Time of Accident
Date of Accident : (MM/DD/YYYY)      Time of Accident:  
2. Person Reporting
First Name:      Last Name:
Telephone Number: - ' -      Secure Fax Number: - -
Relationship to Accident:
I am a(n) (choose one):
3. Insured Information
Insured Name (Company Name):
I use a DBA (Doing Business As) Name:
Address:
City:     State:      Zip: -   
Telephone Number: - -      Contact Name:
Policy Number:       Effective Date: (MM/DD/YYYY)
Agent Name:
Location Information >>
4. Location Information
Location Name:
Address:
City:     State:      Zip: -   
Telephone Number: - -      Secure Fax Number: - -
5. Loss Location Information (where loss occurred)
Location Name:
Address:
City:     State:      Zip: -   
Property Damage >>
6. Property Damage Information
'
Kind of Loss (fire, wind, explosion, etc.):      Probable Amount of Entire Loss:
Date Insured Was Notified: (MM/DD/YYYY)     Time Insured Was Notified:  
Description of Loss and Damage:
Fire, Allied & Multi-Peril Policies (complete only those items involved in a loss)
ITEM 1
Total Amount:      Building:      Contents:      Other:
% of Co-insurance:      Deductible:
Description of Property:
ITEM 2
Total Amount:      Building:      Contents:      Other:
% of Co-insurance:      Deductible:
Description of Property:
ITEM 3
Total Amount:      Building:      Contents:      Other:
% of Co-insurance:      Deductible:
Description of Property:
Was Loss Reported to Police or Fire Department:
If Yes, Name of Department:     Report Number:
Other Insurance >>
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7. Other Insurance - List Companies, Policy Numbers, Coverage and Policy Amounts
1. Company:      Policy #:      Coverage Amount:
2. Company:      Policy #:      Coverage Amount:
3. Company:      Policy #:      Coverage Amount:
Closing Information >>
8. Contact Information
First Name:      Last Name:
Telephone Number: - -     Cell Phone Number: - -
Your Email Address:
If you wish to receive a claim acknowledgement, please enter a fax number to send to: - -
9. Additional Remarks
Enter any additional remarks you would like to make in the space below: