Insurance Claim LAMA

INSURANCE CLAIM LAMA

Use this form to report a claim under the policy identified below. Completing this form truthfully and providing required documentation is a condition of processing under the insurer's claim procedures. The claimant certifies that the information provided is true and correct to the best of their knowledge and understands that deliberate misrepresentation may result in denial of coverage and civil or criminal penalties.

Applicant / Insured Information

Date of Birth:

Policy Details

Policy Type (check all that apply):

Auto   Homeowners   Renters   Commercial Property   Liability   Other

Policy Period:
From   To

Claim Details

Date of Loss:   Time of Loss:

Type of Loss (check all that apply)

Fire   Water / Flood   Wind / Storm   Theft / Burglary   Collision   Vandalism  

Liability / Bodily Injury   Other

Police Report Filed: Yes No

Third Party / Other Insurance

Documentation Checklist

Please indicate documents attached or to be provided:

Photographs of damage
Repair estimates / contractor invoices
Receipts for replaced items
Police report
Medical records / bills
Proof of ownership / valuation
Other supporting documents

Beneficiary / Payee Information

Provide beneficiary or payee details for claim proceeds if payment is to be made to an individual or party other than the insured.

Exclusions & Acknowledgements

The insured acknowledges that coverage is subject to the terms, conditions, exclusions and limitations of the policy. Common exclusions include losses arising from intentional acts, wear and tear, gradual deterioration, war or nuclear hazard, and certain unattended property exposures. The insurer reserves the right to deny coverage where policy terms are not met.

By signing this form the claimant authorizes the insurer and its representatives to obtain records and information reasonably related to this claim, including but not limited to: police reports, medical records, repair estimates, employment records, and other documentation. The claimant further acknowledges an obligation to cooperate with the insurer's investigation and subrogation efforts.

I acknowledge no claim is being made for pre-existing damage not caused by the reported incident.
I understand the insurer may pursue subrogation against liable third parties.
I acknowledge that false statements or material omissions may constitute insurance fraud.

Banking Information for Payment (Optional)

Account Type: Checking Savings

Declaration and Certification

I hereby declare under penalty of perjury that the foregoing statements are true and correct. I authorize the insurer to obtain and disclose information necessary to investigate and process this claim. I agree to cooperate with investigations, to provide reasonable documentation of loss, and to assist in any subrogation or recovery actions. I understand claim payment may be subject to adjustment for policy limits, deductible, and applicable terms. I further acknowledge receipt of a copy of this claim form upon request and understand that any payment issued will reduce the insured recoverable amount accordingly.

Fraud Warning: Any person who knowingly and with intent to defraud submits an application or files a claim containing false, incomplete or misleading information may be subject to civil and criminal penalties, including denial of coverage.

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