Urgent: Major Property Damage & Equipment Loss Claim Intake Form

1. Section 1: Asset ID & Loss Location Metadata - Policy, Facility, Asset & Geographic Intelligence

This section establishes the foundational identification framework for your claim. Accurate metadata ensures proper policy matching, asset verification, and geographic risk assessment. Complete all mandatory fields to prevent processing delays.

Enterprise Policy Number

Policy Holder Legal Entity Name

Facility Identification Code

Facility Registered Address

City/Region

Postal/Zip Code

Country/Territory

Is the loss location different from the facility's registered address?

Yes

No

Provide detailed directions and description of the loss location

Date and Time of Loss Discovery

Discovery Reported By

Reporter Contact Number

Reporter Email Address

Loss Severity Classification

Critical - Total Loss/Operational Shutdown

Severe - Major Damage/Partial Shutdown

Moderate - Significant Damage/Operations Continue

Minor - Limited Damage/No Operational Impact

Affected Asset Registry

	Asset ID	Asset Description	Asset Category	Location within Facility	Insured Value	Quantity Affected	Manufacturer/Model	Date of Purchase/Installation
	A	B	C	D	E	F	G	H
1					$0.00	1
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Are there additional undocumented assets affected?

Yes

No

Describe the undocumented assets and estimated values

2. Section 2: Incident Timeline & Cause of Loss Narrative - Chronological Reconstruction & Causation Analysis

This section captures the temporal sequence of events and root cause analysis. Precise timeline reconstruction and causation narrative are critical for coverage determination and subrogation potential. Provide maximum detail to support claim validity.

Incident Occurrence Date/Time (if different from discovery)

Describe the Other Cause in Detail

Detailed Incident Timeline

	Timestamp	Event Description	Personnel Involved	Action Taken	Supporting Document
	A	B	C	D	E
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Comprehensive Narrative Description of Incident

Were there any witnesses to the incident?

Yes

No

Witness Information

	Witness Name	Contact Information	Relationship to Enterprise	Witness Statement Summary
	A	B	C	D
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Was a third party responsible for or involved in the incident?

Yes

No

Provide third party details, contact information, and evidence of involvement for potential subrogation

Have similar incidents occurred at this facility or other enterprise locations?

Yes

No

Describe previous incidents, dates, and mitigation measures implemented

Was law enforcement or emergency services notified?

Yes

No

Emergency Services Notification Log

	Agency/Department Name	Report/Case Number	Notification Time	Officer/Responder Name	Attach Report
	A	B	C	D	E
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Explain why emergency services were not contacted

3. Section 3: Financial Loss Estimate & Immediate Mitigation Expenses - Valuation, Damage Quantification & Cost Containment

This section quantifies the financial impact and documents immediate response costs. Accurate valuation and expense tracking are essential for claim adjudication and reimbursement. Provide detailed estimates with supporting justification.

Asset Damage Assessment & Valuation

	Asset ID	Asset Description	Damage Extent	Replacement Cost New (RCN)	Actual Cash Value (ACV)	Estimated Repair Cost	Estimated Replacement Cost	Repair vs Replace Decision	Deductible Applicable	Net Claimable Amount
	A	B	C	D	E	F	G	H	I	J
1				$0.00	$0.00	$0.00	$0.00		0	$0.00
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Are there assets with sentimental or historical value that exceed financial valuation?

Yes

No

Describe the special value and provide any appraisals or documentation

Total Estimated Property Damage (all assets combined)

Total Estimated Equipment Loss (all assets combined)

Has business interruption occurred due to this loss?

Yes

No

Business Interruption Impact

	Interruption Start Date	Estimated Resumption Date	Number of Days	Estimated Lost Revenue per Day	Ongoing Fixed Costs	Extra Expense to Mitigate Loss	Total BI Estimate
	A	B	C	D	E	F	G
1			0	$0.00	$0.00	$0.00	$0.00
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Immediate Emergency Mitigation Expenses

	Expense Date	Vendor/Service Provider	Service Description	Amount	Invoice/Receipt	Pre-Approved by Insurer
	A	B	C	D	E	F
1				$0.00
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Total Emergency Mitigation Expenses to Date

Are there anticipated additional mitigation expenses?

Yes

No

Describe anticipated expenses and estimated amounts

Policy Deductible Amount

Estimated Salvage/Recovery Value of Damaged Assets

Total Estimated Claim Amount (Property + Equipment + BI + Mitigation - Deductible - Salvage)

Do you have separate insurance coverage that may also apply (e.g., cyber, marine, cargo)?

Yes

No

Describe other coverage and policy numbers

4. Section 4: Evidence Documentation & Independent Adjuster Log - Proof of Loss & Expert Assessment Trail

This section establishes the evidence chain and documents independent assessments. Robust documentation accelerates claim validation and supports dispute resolution. Upload all relevant materials and log all expert interactions.

Have you captured photographic/video evidence of the damage?

Yes

No

Upload Primary Damage Documentation Photos

Choose a file or drop it here

Do you have 'before' photos/videos of the affected assets?

Yes

No

Upload 'Before' Condition Documentation

Choose a file or drop it here

Are there surveillance/CCTV recordings of the incident?

Yes

No

Upload Surveillance Footage (or describe retention location)

Choose a file or drop it here