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ONLINE LOSS LISTING FORM
You may download a paper copy of this form HERE if preferred.
Step 1: Fill out case information you want to report losses for.
Case Number Victims First Name Victims Last Name Telephone
INSTRUCTIONS: List type of item, give make, model, and serial number, or physical description of the item; i.e., size, color, material, design, men's, women's.
JEWELRY: identify any type of metal (yellow gold, silver, platinum, etc). Indicate the type, size, weight, shape, and color of stones, etc.
FURS: Indicate type of fur, color, size, style, maker or other identification.
GUNS: give manufacturer, model, serial number, caliber, length of barrel, color of weapon & stock, etc.
STEREO-TV: Indicate make, model, serial number, color, black & white, size of screen, etc.
CURRENCY: Indicate whether U.S. or FOREIGN notes and furnish denominations, etc.
BANK CHECKS/TRAVELER CHECKS/CREDIT CARDS: Identify by name or issuer or bank, give serial numbers or account numbers.
NOTE: ITEMS SHOULD BE REPORTED AT ESTIMATED FAIR MARKET VALUE, SUBJECT TO DEPRECIATION.
VALUES INDICATED SHOULD NOT INCLUDE RETAIL REPLACEMENT COST.
Step 2: Add items and property below including make/model and serial numbers if known.
Item Name of Item Make / Model Serial # Description Value  
1
Step 3: Add attachments such as pictures and documents below. (20 Mb max)
THERE ARE CURRENTLY NO ATTACHMENTS UPLOADED TO THIS FORM
YOU MAY UPLOAD UPTO 10 PER FORM.
File To Add Associated Item Brief Description Upload
Step 4: Electronically Sign and Submit
Note: FLORIDA STATUTE 837.06 FALSE OFFICAL STATEMENTS: Whoever knowingly makes a false statement in writing with intent to mislead a public servant in the performance of his official duty shall be guilty of a MISDEMEANOR of the 2nd degree.
Name of Person Filling Out this Form: