Property Damage Claim

PROPERTY DAMAGE CLAIM

Claimant Name:    Claimant Address:

Respondent Name:    Respondent Address:

RECITALS

WHEREAS, Claimant owns, leases, or holds an interest in the real property and/or personal property located at (the "Property");

WHEREAS, on or about , the Property sustained damage described herein as the result of ;

WHEREAS, Claimant seeks recovery of the reasonable and documented costs to repair, remediate, replace, or otherwise compensate for the damage to the Property from Respondent or Respondent's insurer as applicable;

NOW, THEREFORE, in consideration of the mutual covenants and promises contained herein, the parties agree as follows:

1. DEFINITIONS

For purposes of this Claim, the following defined terms apply: "Claim" means the demand for monetary recovery and related relief asserted by Claimant in this document; "Loss" means the direct physical damage to the Property and any reasonable costs of repair, replacement, removal of debris, temporary housing, and other reasonable out-of-pocket expenses as documented by Claimant; "Respondent" includes the named party and any insurer, agent or successor entity through which responsibility or payment may be sought.

2. DESCRIPTION OF DAMAGE

3. ITEMIZED LOSS & ESTIMATE

Estimated Total Loss Amount: $

4. SUPPORTING DOCUMENTATION

Claimant has provided or will provide the following documentation to substantiate the Claim (check all that apply):

Photographs of damage

Contractor repair estimate(s)

Police or incident report

Receipts for emergency repairs or temporary housing

5. INSPECTION AND ACCESS

Claimant authorizes reasonable inspection of the Property by Respondent or Respondent's agents upon at least days' notice. Claimant agrees to make the Property available for assessment and to provide reasonable access to documentation and records necessary to evaluate the Claim.

6. LIABILITY, RESERVATION OF RIGHTS, AND NO ADMISSION

Submission of this Claim is not an admission of liability by any party. Respondent expressly reserves all rights, defenses, and coverage positions. Acceptance of any payment, settlement, or partial payment by Claimant shall not operate as a release of any party except to the extent set forth in a written release signed by all parties.

7. PAYMENT TERMS

Respondent shall make any agreed payment to Claimant or to Claimant's designated payee within days after agreement or final determination of payable amount. Payment shall be by check or wire transfer to the payee designated below unless otherwise agreed in writing.

8. REPRESENTATIONS AND WARRANTIES; CERTIFICATION

Claimant represents and warrants that all statements, documents, estimates and receipts submitted in support of this Claim are true, complete, and accurate to the best of Claimant's knowledge, and that Claimant is the lawful owner or authorized agent with authority to assert this Claim. Claimant certifies under penalty of perjury that the information in this Claim is true and correct.

9. INDEMNIFICATION

Claimant shall indemnify, defend and hold harmless Respondent from and against any losses, claims, damages, liabilities and costs (including reasonable attorneys' fees) arising out of Claimant's intentional misrepresentation of facts material to this Claim, provided Respondent gives prompt written notice of any asserted claim and reasonable cooperation in the defense.

10. NOTICES

All notices required or permitted under this Claim shall be in writing and delivered to the addresses set forth below by certified mail, courier, or personal delivery and shall be effective upon receipt.

11. AMENDMENT; WAIVER; COUNTERPARTS

This Claim may be amended only by a written instrument executed by both parties. No waiver of any provision is effective unless in writing and signed by the waiving party. This Claim may be executed in counterparts, each of which constitutes an original, and all of which together constitute one instrument.

12. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Claim shall be governed by and construed in accordance with the substantive laws of the state identified for governing law: . This Claim constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations and understandings. If any provision is held invalid, the remaining provisions remain in full force and effect.

13. DISPUTE RESOLUTION

The parties shall attempt in good faith to resolve disputes arising from this Claim through direct negotiation. If unresolved within days after written notice, either party may pursue remedies in a court of competent jurisdiction consistent with the Governing Law section above.

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