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Insurance Company Catastrophic/Emergency Adjuster Provision Disaster Declaration
TO BE COMPLETED BY INSURANCE COMPANIES ONLY

Company Name:
Insurance Company NAIC #:
Contact First Name:
Contact Last Name:
Contact Title:
Address:
City:
State:	AK AL AR AZ CA CN CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip:
Phone:
Fax:
Email:
Disaster Name:
Short Description of Disaster:
Areas Affected by Disaster: