Old United Casualty Co.
P O Box 795
Shawnee Mission, KS 66201

Agency:

Policy Number:

Phone Number:

Policy Term:

Fax Number:

Insured

Named Insured: *

Additional Insured:

Home Phone: *

Work Phone:

Cell Phone:

Address:

City, State, Zip:

Fax Number:

Email:

Loss Information

Date/Time of loss: *

Location of loss: *

Type of loss: *

Operator Information:

Description of incident:

Extent of damage:

Police/Fire dept. reported to:

Report Number:

Boat location for inspection:

Contact:

Phone Number:

Other party(ies) involved; Address/contact number: *

Other Insurance Address/phone #:

Any injuries? Yes   No

Description of Injury:

Injured Party (Name/Address/Phone Number):

Insured Property

Vessel:
Yr.    Manufacturer:    Model:    Hin #: