Equity/NAHASDA FNOL

Member/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 do not 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
- All Liability (General, Tribal Housing Management, Liquor & Employment)
- Inland Marine/Equipment Breakdown
Liability Section
Date of Incident
MM slash DD slash YYYY
Discovery Date
MM slash DD slash YYYY
Peril Liability
Other Liability-Explain
Loss Location*
Street Address Address Line 2 City State ZIP 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" was selected)*
Project #
Make and Model
Unit #
VIN or Serial #
Loss Location – (As Listed on Your Inventory)
Street Address Address Line 2 City State ZIP Code
Attach Inventory Spreadsheet
Max. file size: 100 MB.
Attach Schedule / Unscheduled Equipment Spreadsheet
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 inventory form, please send an email request for your inventory to: PCFNOL@amerind.com

Claimant Information
Claimant Name*
First Last
Claimant Address
Street Address 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.
Accepted file types: pdf, docx, doc, Max. file size: 25 MB.
Property-Loss Information
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
- Loss of Use or Extra Expense (Incurred expenses while dwelling is unlivable. Receipts required.)
Occupancy Status*
Utility Status*
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: Incident report, Police report, Bid or Quote proposal, Mitigation (precautionary) invoices, Other documents
Drop files here or

Max. file size: 100 MB.

Step 1 of 4 – Contact Information

Liability Section

Property and Other

Claimant Information

Property-Loss Information

Liability

Property