McQueen Agencies Ltd. - File a Claim (Notice of Loss)

Policy Number:

Applicant's Name and Mailing Address
FIRST	MIDDLE	LAST
STREET OR POST OFFICE BOX
TOWN	PROVINCE	POSTAL CODE
TELEPHONE

NOTICE OF LOSS

A NOTICE OF LOSS must be submitted within 3 days after damage to crop. Advise to local agent is not sufficient.
This form supplied for your convenience.

Today's Date 20
Please take notice that the following growing crops insured under the above policy were damaged by hail on 20 at about (indicate AM or PM)

POLICY ITEM NO.	NO. OF ACRES	KIND OF GRAIN	QTR	SECTION	TWP	RANGE	MER	TYPE OF DAMAGE	STAGE OF GROWTH WHEN HAILED
1

The town nearest the loss

I reside on the quarter of sec twp rge miles of said section.

Note - I am aware that according to the policy under which I am making a claim that if for any reason the insurer is not liable for loss, then I am liable for the expense incurred by the insurer for investigating said claim, and on demand, I promise to pay the insurer all such expenses.

THE INFORMATION BELOW IS REQUIRED UNDER THE PROVINCIAL INSURANCE ACT

Company	Other Hail Insurance on Same Crops	Amount Per Acre

Telephone Telephone Signature of Policy Holder _____________________________________

Power of Attorney

In the event of my absence when your adjuster calls to make an appraisal of this claim, I hereby appoint or to act for me and on my behalf in the adjustment of said loss, and in the capacity to make proof of loss and to do all things required by me to be done persuant 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.

Date ___________ Witness ______________________________ Signature of Policy Holder ______________________________