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Property Claims Form

(Please fill in all the information requested before submitting the form)

Fields mark (*) Are fields

  The Insured
Claim #* Policy Number:* Date Premium Paid:* Renewal Date:*
Insured Name:* Telephone Number: *
Home Address:
  The Event
Date:* Time:*
When and by Whom Discovered: *
State fully what happened: *
Date Police was advised: * Name of Police Station: *
Are you the owner?* Yes No *
State the value of the building: $
If a tenant, are you legally liable under agreement for repairs to the building: * Yes No
Give details of any other party having an interest in the property: *
Are you the sole owner of the articles? *
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:*


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