| WHO
IS TO BE LEAD CONTACT FOR FURTHER INVESTIGATION OR CLAIM
INFORMATION SAME
AS ABOVE |
| Lead
Contact Name:
Phone #:
Email: |
| CLAIM
INFORMATION |
| Date
of Claim Occurrence:
Time of Claim Occurrence:
AM
PM |
| Location
of the Claim (address or specific area): |
Description
of Loss and Damage that Occurred?
|
If an
authority such as police or was contacted, please
name:
What is the report # of the authority, if known: |
| PROPERTY
DAMAGED INFORMATION |
What
kind of loss occured? Fire
Theft
Lightning
Hail
Wind
Storm
Water
Vandalism
Other:
If applicable, have you secured the damaged property to
mitigate further damage? Yes
No
If NO, please do so and keep all receipts for items /
services purchased.
Do NOT throw away damaged item(s). Keep them
in a secure place as the company may need to investigate or view
item(s)
. |
| AMOUNT
OF DAMAGES |
| Estimate
Amount of Damages ($ Amount):
or Unknown
Estimate
is in Process of being completed |