21st Century Homeowners Insurance Program

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Claims First Notice of Loss (Please complete as many sections as apply to your claim.)
Name of Person Submitting Claim:
What is your relationship to the Insured?

Information About the Policy and Policyholder
Policy Number:
Policy Effective Date:
Has This Claim Been Previously Reported?	Yes No

Contact Information and Preferences
Name(s) as they appear on the Policy:
Mailing Address:
City, State, Zip:	,
Daytime Phone:	( ) ext.
Evening Phone:	( )
E-mail:
FAX Number:
How do you wish to be contacted regarding this claim?	By Phone By FAX By E-mail By Mail

Property and Loss Location Information
Property Address: (If different from mailing address)
City:
State:
Zip:

Address Where Loss Occured:(If different from mailing address)
City, State, Zip:	,

Type of Loss

Date of Loss:
Time of Loss:
By Whom ?

Estimated Cost of Repair $
Estimated Cost of Replacement $
Mortgagee (If none, please indicate):
Complete If Loss of Contents or Theft
Property Was In Custody of Whom?
Agency to Which Theft Was Reported:
Was an Investigation Completed?	Yes No
Report #:
Are Police Holding Suspects?	Yes No
Has Property Been Returned?	Yes No
If Yes, Any Damage?	Yes No

Complete If Loss Was Due to Fire
Fire Department Responsible:
What Type of Property Was Damaged:	Building Contents/Estimated Loss $
How Long Property Owner?
Nature of Damage:
Estimated Cost of: Replacement $	Repair $

Name of Injured Parties and Discription (If Applicable):
Name of Injured Party 1:
Address:
City:
State:
Zip Code:
Description of Injury:

Name Injured Party 2:
Address:
City:
State:
Zip Code:
Description of Injury:

Other Insurance
Name of Insurance Company:
Policy Number:
Amount:
Remarks:

Loss Description Cause and Extent of Damage (Please be as specific as possible)
Additional Comments (Describe):

The foregoing is a true statement of the cause and estimated amount of this loss. If approved by the Company, I/we agree to accept this amount in settlement. Statutory Note: Any person who knowingly and with intent to defraud any insurance company submits an application or statement of claim containing false information, or conceals, for the purpose of misleading, information concerning any fact material thereto comits a fraudulent insurance act, which is a crime. ARIZONA NOTICE: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. CALIFORNIA NOTICE: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. COLORADO NOTICE: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent Of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. FLORIDA NOTICE: Any Person who knowingly and with intentto injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information, is guilty of a felony of the third degree. INDIANA NOTICE: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. LOUISIANA NOTICE: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or Knowingly presents false informationin an application for insurance is guilty of a crime and may be subject to fines and confinement in prison MINNESOTA NOTICE: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NEW JERSEY NOTICE: Any person who includes Any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties." All insurance claim forms shall contain a statement "Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties." NEW MEXICO NOTICE: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NEW YORK NOTICE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OHIO NOTICE: Any person who, with intent an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. OKLAHOMA NOTICE: Warning: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes a claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OREGON NOTICE: Willfuly falsifying material facts on an application or claim may subject you to criminal penalties. PENNSYLVANIA NOTICE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. TENNESSEE NOTICE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. VIRGINIA NOTICE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Before submitting this report, make sure that all questions have been fully answered, thereby enabling the company to serve you better in conjunction with your reported loss.

*21st Century is not affiliated with Homesite Insurance. The 21st Century Homeowners Insurance Program is underwritten by member companies of the Homesite Insurance group, a leading provider of homeowners, renters and condominium insurance. Member companies include: Homesite Insurance Company, Homesite Indemnity Company, Homesite Insurance Company of California, Homesite Insurance Company of Florida, Homesite Insurance Company of Illinois, Homesite Insurance Company of the Midwest, Homesite Insurance Company of New York, Homesite Insurance Company of Pennsylvania, and Homesite Lloyd's of Texas.