Insurance Flood Claim Document

INSURANCE FLOOD CLAIM DOCUMENT

Claimant / Insured Information

Date of Birth:    Preferred method of contact: Phone Email

Property and Loss Location

Property Type: Primary residence Secondary residence Rental Commercial

Year property built:    Occupied at time of loss: Yes No

Policy Coverage Details

Coverage Types (check all that apply):
Dwelling coverage Personal property / contents Other structures Additional living expense (ALE)

Deductible Amount:    Policy Period From:    To:

Loss / Incident Details

Date of Loss:    Time of Loss:

Cause of Flood (check all that apply):
River overflow Storm surge Stormwater / surface runoff Sewer or drain backup Other (explain below)

Itemized Damage / Inventory (Provide best estimate)

Item 1

Quantity:    Age/Condition:    Estimated Loss:

Item 2

Quantity:    Age/Condition:    Estimated Loss:

Item 3

Quantity:    Age/Condition:    Estimated Loss:

Additional Notes on Inventory

Temporary Repairs and Mitigation

Were temporary or emergency repairs performed to prevent further damage? Yes No

Supporting Documentation Checklist

Please indicate which of the following are attached or will be submitted:
Photographs of damage Receipts and proof of ownership Contractor repair estimates Official reports (police/fire/municipal) Building permits Prior claim documentation (if any)

Prior Losses / Claims

Have you submitted any prior flood or water damage claims on this property? Yes No

Payee / Beneficiary / Mortgagee Instructions

If proceeds are to be made payable to an entity other than the insured (mortgagee, lienholder, or designated payee), provide details below.

Certification and Authorization

By submitting this claim I certify, under penalty of perjury and subject to applicable insurance fraud statutes, that the information contained herein and in all attachments is true, accurate and complete to the best of my knowledge. I understand that any intentional misstatement, omission or concealment of material facts may constitute insurance fraud and may void coverage.

I authorize the insurer and its representatives to inspect the damaged property, to obtain repair estimates, and to obtain records from other insurers or providers relevant to this claim. I agree to cooperate with reasonable requests for documentation, examinations under oath, and release of information necessary to process this claim. I acknowledge the insurer's rights of subrogation and agree to assign salvage to the insurer where applicable.

I further certify that no payment has been received from any other insurer or source for the damages claimed herein unless specifically disclosed in this form and accompanying documentation.

I affirm the above by checking the box and signing below: I certify and authorize

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