FNOL 3.0

We are committed to the privacy and confidentiality of personal information. We collect, use and disclose personal information in accordance with applicable law. The personal information collected on this form will be used to handle and investigate the insurance claim. For more details, please see our Privacy Policy at www.ecclesiastical.ca.

First name of the person who is reporting the loss
Last name of the person who is reporting the loss
Relationship to the claimant
Phone number of the person who is reporting the loss
Email of the person who is reporting the loss; please ensure this email address is correct

Insured Details

Insured organization name
Policy number that covers the insured
If covered under a program, provide program name
If covered under a program, provide certificate name
If covered under a program, provide certificate number

Contact Details

First name of the individual who can be contacted with regards to the claim
Last name of the individual who can be contacted with regards to the claim
Phone number for claim related correspondence
Email for claim related correspondence

Broker Details

Name of Brokerage
Broker contact name for the claim
Broker phone number for the claim
Broker email address for the claim

Claim Details

Date of incident
Loss Location *

Location of incident (Full Address)
Suite/ Unit
Suite/ Unit
Street Number *
Street Number & Name
City/ Municipality *
City/ Municipality
Province *
Province
Postal Code *
Postal Code
Loss Type *
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Maximum upload size: 20MB

Please review your information before submitting