Notice of Loss

1Form

2Review

Policy Number(Required)

Insured

Name / Company(Required)

Contact Name(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Primary Phone(Required)

Secondary Phone

Agent

Agent Name

Agent Number

City/Town

Crop Information

Storm Date(Required)

Time(Required)

Policy Item #

# of Acres

Crop Type

Qrt

Sec

Twn

Rge

Mer

Type of Damage

Stage of Growth

Add additional policy items by clicking the plus sign (⊕) icon at the end of the row. To remove a policy item, click the minus sign (⊖).

Town Nearest the Loss(Required)

Residence Location

I reside in

Street Address

Quarter

Section

Township

Range

Meridian

Additional Insurance

The information below is required under the Provincial Insurance Act.

Do you have other insurance?(Required)

Yes

Additional Insurance Information(Required)

Company

Amount Per Acre

Power of Attorney

In the event of my absence when your adjuster calls to make an appraisal of this claim, I would like to assign power of attorney(Required)

Yes

I hear-by appoint

Name(Required)

Of (nearest town)(Required)

Phone(Required)

to act for me and on my behalf in the adjustment of the said loss, and in that capacity to make proof of loss and to do all things required by me to done pursuant to the statutory conditions of the said policy, and I hereby ratify all that my said attorney may do in connection with such appraisal and adjustment.

Power of Attorney(Required)

By checking this box I confirm the above power of attorney information.