b_and_c_logo.jpg (16888 bytes) Insurance for North Carolina
708 Spartanburg Hwy, Hendersonville, NC 28792
(828) 692-8277, Fax:(828) 696-8181, Email
Hours: Mon. - Friday, 8:30 a.m. - 5:00 p.m.
Barnette and Coates Insurance, Inc.
Home Insurance Claim Form

indins.jpg (14767 bytes)

Contact Information:

First name
Last name
Middle initial
Street address
Address (cont.)
City
County
State
Zip/Postal code
Home Phone
Work Phone
FAX
E-mail

Policyholder Information:

Policy #
Check box if the Policyholder Name and Telephone Number is the same as "Contact Information".
Daytime Phone
Policy Holder Address
Address (Cont.)  
Policyholder City
Policyholder State:
Policyholder Zip Code

Homeowners Loss/Incident Information:

Date of the Incident  // MM/DD/YY
Incident Time HH:MM   AM PM

Use this space to enter a brief description of the incident:

Contacted Fire/Police? Yes No

Police/Fire Report Number:

Police/Fire Department Name:

Any injuries as result of the incident? Yes No

Were there any witnesses present? Yes No

If there were any injuries as a result of the incident, please list the Name, Address, Phone Number, and the extent of the injuries of the persons injured in the box below this line.

Property Damage Information:
Was the property of the policyholder damaged? Yes No

If the policyholder property was damaged, please provide a description of the damage in the box below.

If other parties were involved in the incident, please provide contact information for each of the other parties in the box below: