Insurance Property Damage Claim

INSURANCE PROPERTY DAMAGE CLAIM

Claim Information

Claim Number:    Date Reported to Insurer:    Time of Loss:

Insured / Claimant Information

Date of Birth:    Phone:    Email:

Policy Information

Policy Number:    Policy Type:

Coverage Amount (Limit):    Deductible:    Current Premium:

Policy Period From:    To:

Loss Details

Date of Loss:    Time of Loss:    Cause of Loss (check all that apply):

Fire Water damage (include source) Wind / Storm Theft / Vandalism Other

Report Filed:    Report Number:    Agency:

Damage Description and Inventory

Provide a detailed description of the damage and list damaged items. Attach additional pages if necessary.

Estimated Damage & Interim Repairs

Estimated Total Loss:    Amount of Interim/Triage Repairs (to prevent further damage):

Yes No

Coverage Claimed

Select coverage components applicable to this claim (as claimed by insured):
Dwelling Other Structures Personal Property Additional Living Expense (ALE) Loss of Use Debris Removal Ordinance or Law

Exclusions & Acknowledgement

The following are common exclusions under most property policies. This list is a non‑exhaustive notice of exclusions that may apply to this claim. Insurer reserves the right to deny coverage to the extent an exclusion is applicable under the policy terms and conditions.

• Wear and tear, gradual deterioration, and maintenance-related losses.
• Flood, surface water, storm surge, and tsunami, unless specifically endorsed.
• Earth movement, earth subsidence, sinkhole and volcanic activity, unless specifically endorsed.
• Intentional acts by the insured or failure to protect property after loss.
• Government action, nuclear hazard, and war risks.

I acknowledge that I have read the exclusions above and that the insurer may deny payment for loss types expressly excluded by my policy. Initials:

Additional Interested Parties / Payee Information

If payment is to be made to a mortgagee, lienholder, mortgage company, or other payee, provide their information below.

Relationship to Insured:    Percentage of Proceeds (if applicable):

Documentation Checklist

Please indicate documents attached to support this claim:

Photographs of damage Original receipts / proofs of ownership Contractor / repair estimates Police / incident report Building permits / prior appraisals

Authorization & Inspection

By signing below, I authorize the insurer, its representatives, and any appointed adjusters to inspect the damaged property, obtain repair estimates, and review records relevant to this claim including but not limited to property records, medical records (if applicable), and proof of ownership. I agree to cooperate fully with reasonable requests for documentation and access to the property.

I understand and agree that the insurer may undertake subrogation and recovery efforts against responsible third parties, and I will cooperate in those efforts and execute documents necessary to secure the insurer's subrogation rights. Any payment issued to the insured may be payable jointly to the insured and any mortgagee or lienholder shown above as required by the policy.

Fraud Warning & Certification

WARNING: Any person who knowingly and with intent to defraud any insurance company files a statement of claim containing materially false information or conceals for the purpose of misleading information concerning any fact material thereto may be guilty of insurance fraud and subject to criminal and civil penalties in accordance with applicable law.

Certification: I certify under penalty of perjury that the information provided in this claim form and any attached documents is true, complete, and accurate to the best of my knowledge. I understand that making false statements may result in denial of coverage and may subject me to civil and criminal penalties.

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