Property Insurance Claims


The Insured

Claim # Policy Number:* Date Premium Paid: Renewal Date:
Insured Name:* Telephone Number: *
Home Address: *

The Event

Date:* Time:*
Place:*
When and by Whom Discovered: *
State fully what happened: *
Date Police was advised: * Name of Police Station: *

Building

Are you the owner?* State the value of the building: $
If a tenant, are you legally liable under agreement for repairs to the building: * Give details of any other party having an interest in the property: *

Contents

Are you the sole owner of the articles? Yes No
Yes No
Name of owner: Address of owner:
Are there other insurances on the articles? Yes No
State the total value of contents on your premises at the time of loss: $
Have you previously made a claim of this nature upon any company? Yes No
Building
Specify separately each room damaged or destroyed Age of Building or damaged fixtures, fittings, etc. Estimate Deduction of Depreciation Net Amount of Claim
I/We declare that the particulars upon this form are true and complete *
Date: Signature: