Company ____________________
Fill in appropriate name of Hail company

Policy Number ____________________

Name and Address of Applicant:

A NOTICE OF LOSS must be signed by the assured and mailed within 3 days after damage to crop. ADVISE TO LOCAL AGENT IS NOT SUFFICIENT. Send a notice direct to the office issuing the policy whose address is printed above. Any letter form of reporting a hail loss is acceptable.

This form supplied for your convenience.

Today's Date______________________ 20____
Please take notice that the following growing crops insured under the above policy were damaged by hail on _________________ 20_____ at about ___________ O'clock am / pm (circle one).

Policy Item No. No. of Acres Kind of grain qtr sec twp rng mer type of damage light medium heavy stage of growth when hailed

The town nearest the loss __________________________________________
I reside on the _________ quarter of sec _____ twp _____ rge ____, ____ miles _____ of said section.

Note - I am aware that according to the policy under which I am making claim that if for any reason the insurer is not liable for loss, then I am liable for the expense incurred by the insurer investigating said claim, and on demand, I promise to pay the insurer all such expense.

The information below is required under the provincial insurance act.

Company Other hail insurance on same crops amount per acre
_____________________ _____________________________ ____________
_____________________ _____________________________ ____________
_____________________ _____________________________ ____________
(___)______________ (___)______________ __________________
telephone telephone policy holder signature


In the event of my absence when your adjuster calls to make an appraisal of this claim, I hereby appoint________________________of ______________________________ to act for me and on my behalf in the adjustment of the said loss, and in that capacity to make proof of loss and to do all things required by me to be done pursuant to the statutory conditions of the said policy, and I hereby ratify all that my said attorney may do in connection with such appraisal and adjustment.

____________________ _______________________ ________________________
date witness signature of policy holder