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Pursuant to Paragraphs (b) and (i) of the Property Fire Loss Act, Chapter 73, Section 1153 of the Illinois Revised Statutes, (Public Act 80-488 as amended by PA 84-394) a copy of which is attached, request is being made for release of your investigation file, including factual reports, statements of witness, photographs, cause of origin reports, police and fire department reports of the fire described below. The information is being requested as insurer of the interests of the insured in the real and/or personal property involved in the fire loss described below. The requested information will be held in confidence until such time as its release is required, pursuant to the Property Loss Act or criminal or civil proceeding.
Insurer's Name: Address of Fire: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Incident or Case Number: Our Claim Number: Policy Number: Information Requested:
Please release information to:
Company Name: Company Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Company Phone Number: Company Email:
