Agent / Broker FNOL

Need to File a Claim on behalf of your client? The First Notice of Loss (FNOL) is the initial report made to your insurance AMERIND following a loss. You can submit with our ONLINE SUBMISSION form below. If you need assistance, the Claims team at AMERIND is ready to answer your questions and guide you through the claims process. You can reach us at PCFNOL@amerind.com.

FNOL – Broker Final

Step 1 of 3 – Contact Information

Brokerage Firm*
Agent / Broker Name*
First Last
Agent / Broker Phone*
Agent / Broker Email*
Policyholder/Insured Name
Primary Contact
First Last
Contact Phone (Pref. Cell #)*
Work Phone
Extension
Email*
Note: All claim information such as Acknowledgement letter, Declination letters and Settlement forms will be sent to the Primary Contact Person.
As well as, our Third Party Adjuster will be in contact with the Primary Contact person to schedule the site inspection

Policy #
Please omit the zeros and -01 when you enter your policy number. Examples of the policy number to be entered: EQ 1234
Check this box if you don't know the policy #
We apologize, unfortunately your First Notice of Loss (FNOL) may NOT be submitted online at this time. Please email your FNOL or any questions about the claims process to: PCFNOL@amerind.com Thank you!
Type of Submission*
- Property
- General Liability
- Inland Marine
- Equipment Breakdown
Liability
Date of Incident
MM slash DD slash YYYY
Discovery Date
MM slash DD slash YYYY
Peril Liability
Other Liability (explain in short description)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Property and Other
Date of Loss*
MM slash DD slash YYYY
Discovery Date*
MM slash DD slash YYYY
(Peril) Choose a Loss Type*
Peril Description (Peril Not Listed selected)*
Loss Location – (As Listed on Your Property Schedule)*
Street Address Address Line 2 City State ZIP Code
Attach Property Schedule
Accepted file types: csv, xls, xlsx, Max. file size: 100 MB.
Please upload file as an Excel Spreadsheet with the highlighted unit that has sustained damage.
If you have multiple properties with the same peril, and date of loss, upload inventory with ALL highlighted units that have sustained damage here.

If you do not have your property schedule, please send an email request for your inventory to: PCFNOL@amerind.com

Claimant Information
Claimant Name
First Last
Claimant Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Claimant Phone Number
Claimant Date of Birth
MM slash DD slash YYYY
Claimant Email Address
Claimant SSN
Description of Incident
Attach Incident Report
Please upload all pertinent information including Accord Forms, medical bills and reports, incident reports, and all other documents associated with submission.
Drop files here or

Max. file size: 100 MB.
Was a Summons and Complaint Received?
Upload Files
Summons or Complaint Files
Drop files here or

Max. file size: 100 MB.
Date Served
MM slash DD slash YYYY
Was a police report requested?
Upload police report
Drop files here or

Max. file size: 100 MB.
Was Medical Care Requested?
Medical Facility Name
Medical Facility Phone Number
Property and Other
How did the loss occur?*
Please provide a brief description of the cause of your loss. (Example descriptions: a fire on the stove from a cooking accident OR water damage from an interior frozen pipe burst.)
Describe the damages sustained from Cause of Loss.*
(Example descriptions: fire damaged my cabinets, flooring, walls, windows, and personal contents OR water damaged my flooring, walls, and personal contents)
Describe your Property Loss Severity Level
Damage sustained under policy*
- Building / Dwelling
- Other Structures (chickee / de-attached garage / shed, fences or pools etc.)
- Business/Personal Property
- Business Income or Extra Expense (Incurred expenses while dwelling is unlivable. Receipts required.)
Have you taken photos?
Photos*
Photos are recommended.

If you have suffered a fire, water, or total loss, photos are required.
Photos*
Drop files here or

Accepted file types: jpg, png, bmp, jpeg, Max. file size: 20 MB, Max. files: 10.
Other documents?
Examples: ACORD Form, Incident report, Police report, Bid or Quote proposal, Mitigation (precautionary) invoices, Other documents
Drop files here or

Max. file size: 100 MB.
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Phone
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FNOL – Broker Final

Step 1 of 3 – Contact Information

Liability

Property and Other

Claimant Information

Property and Other