Notice of Loss

Full Name:	Policy Number:
Callsign:	Phone:
Address:	E-mail:
Address2:
City: ST: Zip:

Dear Policy Holder:

So that we can process you claim quickly and efficiently, please complete this screen in as much detail as possible. Prior authorization from HRIA is required BEFORE your equipment can be replaced. We will be in touch with you as soon as possible.

Date of Loss:
Time of Loss:
List below the property that has been lost or damaged. Be sure that you include the manufacturer's name, model and serial numbers, purchase dates and the current replacement cost of the equipment.
Tell us what happened:
Please send copies of the original sales receipts, current repair or replacement cost estimates, shipping receipts, etc. Also include a picture of the damaged equipment. If your equipment was stolen, you must provide us with a copy of the police report. Please put you CALL SIGN ON ALL correspondence.
Please mail your correspondence to:

HAM RADIO INSURANCE ASSOCIATES, INC.
P.O. Box 201
Canonsburg, PA 15317-0201
Fax: (412) 221-7035

POLICIES ARE UNDERWRITTEN BY THE AMERICAN NATIONAL FIRE INSURANCE COMPANY. LICENSING AUTHORITY AND PRODUCT AVAILABILITY VARIES BY STATE. THE PRECISE COVERAGE AFFORDED IS SUBJECT TO MEETING UNDERWRITING GUIDELINES AND THE TERMS, CONDITIONS AND EXCLUSIONS OF THE POLICY AS ISSUED.