Property Claims

Claim #	Policy Number:*	Date Premium Paid:	Renewal Date:

Insured Name:*	Telephone Number: *

Home Address: *

Date:*	Time:*

Place:*

When and by Whom Discovered: *

State fully what happened: *

Date Police was advised: *	Name of Police Station: *

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: *

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

Upload Property Photos: (To upload multiple photos click browse and select photo by holding the Ctrl Key and Clicking on image)
I/We declare that the particulars upon this form are true and complete *
Date:	Signature:

Site Design By SE Technology