Insurance Claim Hurricane App

INSURANCE CLAIM — HURRICANE APPLICATION

Claim Identifiers

Claim Number:    Policy Number:

Claimant / Insured Information

Date of Birth:    Phone:    Email:

Policy Details

Policy Type: Homeowners Dwelling Commercial Condominium Mobile Home

Coverage Limit: $    Deductible: $    Annual Premium: $

Policy Period From: to

Loss Details

Date of Loss:    Time of Loss:

Wind / Windstorm Storm Surge Flood Heavy Rain / Water Intrusion Falling Trees / Debris Other:

Estimated Total Damage: $    Property Habitable?: Yes No

Property & Personal Property Items

Additional Interested Parties / Payee Designation

Relationship to Insured:    Payment Percentage to Payee:

Documentation Checklist (attach copies)

Photographs of damage Receipts or proof of purchase Contractor estimates Police / emergency report (if applicable) Proof of ownership or title Other documents (specify below)

Coverage Acknowledgements and Common Exclusions

The claimant acknowledges that coverage is subject to the terms, conditions, limitations and exclusions of the policy. The following are common exclusions that may apply unless specifically endorsed: flood loss (including storm surge) where a flood endorsement or separate flood policy is required; normal wear and tear; consequential loss, latent defects, or ordinance or law without specific coverage; pre-existing damage; punitive or exemplary damages; nuclear, war, and governmental seizure. This list is illustrative and not exhaustive.

Acknowledgement of reading exclusions: I acknowledge I have read and understand the common exclusions above

Certification, Authorization & Important Notices

By signing below, I certify under penalty of civil liability and possible criminal prosecution for insurance fraud that the information provided in this claim form and any attachments is true and complete to the best of my knowledge. I authorize the insurer, its representatives and any persons acting on their behalf to inspect the damaged property, to obtain and review relevant records and documentation necessary to evaluate and process this claim, and to disclose claim information to any mortgagee, lienholder, adjuster, contractor, or other parties with an interest in the loss.

I understand emergency or temporary repairs may be made to prevent further damage, but I will not make permanent repairs that would affect the insurer's right to inspect without prior approval, except where emergency measures are required to protect health and safety. I authorize payment of claim proceeds to be made to the named mortgagee or payee identified above as necessary to satisfy recorded interests. The insurer reserves all rights of subrogation.

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