Tri-Cot Initial Loss Report Form

Triangle Insurance Company

Friday, May 09, 2008
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Tri-Cot Intial Loss Report Form

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Date of Loss*
Tri-Cot Policy Number*	Policyholder Name*
Tri-Cot Policy Number*	Policyholder Name*
Address*
City*	State*	Zip Code*
Telephone Number*	Fax Number*
Producer's Name*	Farm Name
Location of Loss
Cause of Loss*	Type Of Loss*	Location *	Salvage*
Approximately how many bales were lost?*
Name of Person Who Reported the Loss*
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*Required

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Tri-Cot Initial Loss Report Form

Equipment Breakdown

First Report of Injury

Triangle Insurance Company

Home Office - Enid, OK

(800) 894-5020

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