Property First Notice of Loss

Official Notice (Upon Submission) will be sent to:

NLC Mutual Insurance Company
c/o Davies Group
Attention: Matt Jacobs, VP
199 Rosewood Drive Suite 310
Danvers, MA 01923-4539

Questions:

Matt Jacobs
Office: (978) 745-6655 ext. 9005
Direct: (978) 705-4460
matt.jacobs@us.davies-group.com

From:

Date:

Type of Claim:

Email (required)

Name of Pool: (required)

Claim Number:

Date of Loss:

Pool SIR

Date Claim Made:

Date Reported to Pool:

Original Insured (Entity Member Name): (required)

Insured (Entity Member) Policy Limits:

Insured (Entity Member) Deductible/Retention:

Effective Date of Insured (Entity Member) Coverage

Description of Property Involved (building, contents, equipment, etc.)

Description of Damages/Loss:

Reserve Information

Loss:

Paid Amount:

Outstanding Reserve:

Incurred Amount:

Expense:

Paid Amount:

Outstanding Reserve

Incurred Amount

Notes (for any information that does not fit in the above):

Please attach relevant background and support, including Claim Investigative Reports, Appraisals, Opinions from Legal Counsel, etc.

or drag files here.

NOTE:

Information submitted via this page will not be encrypted for transmission. As such, protected health information and personally identifiable information should not be included. You may submit such information to Davies directly via agreed, secure means subsequent to filing this FNOL.

When you click Submit below, a copy of this FNOL form will be sent to Davies and NLC Mutual for review. You will also receive a confirmation email.