Contents Claim

Initial Claim Questionnaire

Policy Information:

Name 1 *

Name 2 *

Email *

Home Phone *

Cell Phone *

Can we text you? *

Claim Address *

City *

State *

Zip code *

Is the Claim address the Same as Mailing Address? *

Insurance Information:

Insurance Information: *

Policy Number *

Claim Number *

Mortgage Information:

Mortgage Company *

Loan Number *

Is the home for sale *

Are you currently refinancing? *

Building Information:

Is this your primary residence or rental? *

Please list the number of residents in this house. *

Usage *

Year Built *

Year Purchased *

Square footage of Building *

Has the home had Home Inspections? *

Any Issues? (Please list them here) *

Number of stories: *

Easy access to property *

Additional information (copy)

Claim Information:

Were you home when the claim occurred? *

Additional information

Do you have photos or videos of the claim? *

if not, how long were you away?

Do you have prior claims on the property? *

Additional information

Closed / Paid / Repaired? *

Additional information

Fire Investigation: *

Additional information

Water Damage: *

Additional information

Boarded Up: *

Additional information

Preferred Vendor: *

Additional information

Packout: *

Additional information

Items Removed: *

Additional information

Salvageable Clothing: *

Additional information

Injuries or Hospitalization: *

Additional information

Pets / Boarding: *

Additional information

Bird(s) #:

Cat(s) #:

Dog(s) #:

Other(s) #:

ALE Information:

Out of Pocket Expenses:* *

Additional information

Advancement Payments: *

Additional information

Contractor Information:

Do you have a contractor? *

Contractor information

Contents Claim

Initial Claim Questionnaire

Policy Information:

Insurance Information:

Mortgage Information:

Building Information:

Claim Information:

ALE Information:

Contractor Information:

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