CLAIMS FORM - NOTICE OF LO P.O Box 2077 Stillwater, OK 74076 Toll Free: (800) 620-2885 Fax: (405) 708-5240 Email: [email protected] Customer Name StudentName Mailing Address City/ State/ Zip Policy Number Coverage/ Deductible Contact Person Contact Email Contact Phone Type of Loss

Accidental Damage

Theft

Fire/Flood/Natural Disaster Power Surge by Lightning

Date of Incident Make/ Model Serial Number Describe in Detail the Circumstances of the Incident

Michele Bosler Claim Adjuster [email protected] 405-533-7919 Fax 405-334-5418

Vandalism

F LOSS

Email Label Only Box and Label

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