Claimant Name(s)
Current Contact Phone
Email Address
Street Address Line 1
Street Address Line 2
City
State/Province
Postal/Zip Code
Insurance Company Name
Policy Number
From:
To:
Claim Contact Person (if different)
Street Address Line 1
Street Address Line 2
City
State/Province
Postal/Zip Code
Is the property your primary residence?
Is the property mortgaged?
Mortgage Company Name
Mortgage Loan Number
Were you present at the property when the loss occurred?
If Rental Property, Tenant Name & Phone
Date of Loss
Time of Loss (Approximate)
Type of Loss
Choice A
Choice B
Fire
Hail
Theft
Burst Pipe
Vandalism
Other:
Brief Description of how the loss occurred: (Be specific, e.g., "A tree fell onto the roof during a windstorm," or "The kitchen sink supply line burst.")
Was the loss reported to the Police or Fire Department?
Police/Fire Department Agency Name
Report/Case Number
Name of Investigating Officer (if applicable)
Location of Damage (e.g., Roof, Kitchen, Basement, Exterior wall):
Specific Materials Damaged (e.g., Shingles, Drywall, Hardwood Flooring):
Estimated Extent of Damage: (e.g., "50 square meters of roof damage," or "Complete flooding of the ground floor.")
What immediate actions were taken to protect the property from further damage? (e.g., Turning off water, covering a broken window, professional boarding-up.)
Name of Emergency Service Company Used (if any):
Is the property currently uninhabitable due to the damage?
Are you temporarily staying elsewhere?
If Yes, Name/Location of Temporary Residence:
Start Date of Temporary Housing:
Complete this section only if Personal Property was damaged or stolen.
Item Description | Location in Home | Date Acquired (Approx.) | Original Cost (Approx.) | Replacement Cost Est. | Condition Before Loss | ||
|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | ||
1 | |||||||
2 | |||||||
3 | |||||||
4 | |||||||
5 |
Attach an official Inventory of Damaged/Stolen Personal Property if the list is extensive.
Was the loss caused by another party? (e.g., Contractor error, neighbor's tree)
If Yes, Name of Responsible Party/Entity
Do you have other insurance policies that may cover this loss? (e.g., Renter's, Flood, Umbrella)
Other Insurance Company Name
Policy Number
Item Name | Upload File | Tick ✔️ | ||
|---|---|---|---|---|
A | B | C | ||
1 | Photos of the damage | |||
2 | Video of the damage | |||
3 | Police/Fire Report (if applicable) | |||
4 | Estimates/Invoices for emergency repairs | |||
5 | Detailed Personal Property Inventory (if necessary) | |||
6 | Receipts for damaged items (if available) |
I hereby certify that the information provided in this claim form is true, accurate, and complete to the best of my knowledge and belief. I understand that any false statement or material omission may result in the denial of this claim.
Claimant Signature
To configure an element, select it on the form.