Name: Miller Insurance & Financial Services
Address: At The Greene, Beavercreek, OH, 45440, US
Telephone: (937) 427-3600

General Information
Insured Name:*
Legal Name of Business:
Address:
Street Address Address Line 2 City State ZIP Code
Reporter's Name:
Business Phone:*
Email:*
We can call you at a good time for you for any necessary quote information or you can answer the questions below.
Loss Information
Date of Loss:
Month
Day
Year
Time of Loss:

: Hours

Minutes

AM/PM
Location of Accident/Occurence:
Description of Accident/Occurence:
Type of Loss:
Please Describe:
Estimated Loss
Property:
Real Property:
Business Income:
Number of Days:
General Liability
Injured Persons
Name Telephone Extent of Injury
Damaged Property
Owner:
Telephone:
Description:
Additional Comments or Questions
Phone
This field is for validation purposes and should be left unchanged.

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Name	Telephone	Extent of Injury

Business Loss Notice Form

General Information