Notification of Property Claim

      Type of Claim:  
  Name:  
 

Address:

  
  Policy Number:  
  Policy Effective Date:  
  E-mail:  
 

Agency:

  
  Agent:  
  Residence Phone:  
  Mobile Phone::  
 

         Business Phone:

  
       
 

 Property Claim

 
       
 

Residence or Primary Location Address:

 

  
       
       
 

Residence or Secondary Location Address:

  
       
 

                                        Type of Claim:

  
       
 

  Description of the Incident:

 

  
       
       

Real Legacy Assurance Company, Inc.

P.O.Box 71467
San Juan, P.R.
00936-8567

Metro Office Park
Calle 1 Lote 4
Guaynabo, P.R. 00968

Subsidiary of

2006 ® Real Legacy Assurance. All rights reserved.