Insurance Claim Dwelling Fire Application

INSURANCE CLAIM — DWELLING FIRE APPLICATION

Claimant / Insured Information

Claimant Name:   Policy Number:

Policy Details

Insurer Name:   Agent/Broker:

Policy Effective Date:   Policy Expiration Date:

Location of Loss / Property Information

Dwelling Type: Single-family Multi-family Mobile/Manufactured

Construction Type:   Year Built:

Occupancy at Time of Loss: Owner-occupied Tenant-occupied Vacant

Loss Details

Date of Loss:   Time of Loss:

Fire Department Notified: Yes No   Fire Department Name:

Fire Report Number:   Police Report Number (if applicable):

Damage, Loss Estimate & Property Inventory

Estimated Structure Damage: $   Estimated Contents Loss: $

Estimated Additional Expenses (e.g., ALE, debris removal): $   Total Estimated Loss: $

Coverage and Loss Components

Applicable Coverages (check all that may apply): Dwelling/Structure Personal Property / Contents Additional Living Expenses (ALE) Debris Removal Ordinance or Law

Exclusions & Acknowledgment

The claimant acknowledges that coverage determinations are subject to policy terms, conditions and exclusions including, without limitation, losses caused by intentional acts, progressive deterioration, maintenance-related damage, wear and tear, pest infestation, and loss due to nuclear hazard or war risk. This form is not an admission of coverage or liability by the insurer.

I acknowledge receipt of and understand the foregoing statement regarding exclusions.

Mortgagee / Loss Payee / Beneficiary

Relationship to Insured:   Percentage of Proceeds:

Attachments / Supporting Documentation Checklist

Please attach copies where available: Photographs of damage Fire department report Police report (if applicable) Repair estimates / contractor bids Receipts / inventories of lost items Other supporting documents

Prior Loss History

Has the insured had any prior fire or property loss in the last five (5) years? Yes No

Authorization, Certification & Fraud Warning

Authorization: I hereby authorize the insurer, its representatives and any investigating agents to inspect the damaged property, to obtain medical and repair records, and to secure copies of any documents relevant to this claim from any person or entity having records pertaining to the loss. I authorize release of such records to the insurer, its agents, adjusters, contractors and reinsurers for the purpose of processing this claim.

Certification: I certify under penalty of perjury that the information contained in this application is true, complete and correct to the best of my knowledge and belief. I understand that false statements or material misrepresentations made in support of this claim may constitute insurance fraud and may be subject to civil or criminal penalties under applicable law.

By signing below, I authorize payment of claim proceeds to the mortgagee or loss payee named above as their interest may appear. I further certify that I will cooperate fully with the insurer in the investigation and adjustment of this claim.

Additional Statements

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