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 Business Loss Notice 

Business Loss Notice

Contact Information
Your Full Name:
(as listed on policy now)
Your Email Address:
Daytime Telephone Number:
Description of Loss:
Time & Date of Accident/Claim:
 Time AM PM
Date
Location:


Type of Accident/Claim:

Property
Liability
Automobile
Workers Comp
Other:

Description of Loss:
Name(s) of Injured Parties:
Vehicle Description (applicable to Auto Claims Only):

Driver Name (applicable to Auto Claims Only):
Any Additional Information Not Requested Above:
Please Note: Insurance coverage cannot be bound without a written binder from our office.

Enter the security code you see above. Code is NOT case sensitive. *
  • Richard Fox: richard@bestaia.com
  • Howard Lasky: howard@bestaia.com


Fox & Lasky Agency, Inc dba
Arizona Insurance Associates
1450 N Dysart Road, Suite A9
Avondale, Arizona 85323
Office: (623) 925-9000
Fax: (623) 925-9090
Email: info@bestaia.com

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