MBPIA Claim Loss Notice Page

Michigan Basic Property Insurance Association^®3245 E. Jefferson
Detroit, MI 48207
313-877-7400

Richard Robertson, General Manager

Instructions:

To report your claim directly to MBPIA, all fields contained in this form must be properly completed. Once complete, click the "Submit" button at the bottom of this page.

Please use the "Comments" box to provide us with any additional details that you feel are important regarding this claim.

Please allow us two business days to initiate contact with you.

Policy Data
	Policy Number:
	Effective Date:


Loss Data
	Date of Loss:
	Type of Loss:
	Board-Up Required?
	Loss Address:
	Loss City:
	Loss State:
	Loss Zip Code:
	Description/Details:

Agency Data
	MBPIA I.D. Number:
	Agency Name:
	Claim Reported By:

Person To Contact
	Name:
	Phone # 1:
	Phone # 2:
	Fax #:
	Email address:
	Contact via:

Comments