Home Claim Information NeededName(Required) First Last Person to Contact(Required) First Last Best Way to Contact(Required) Phone Text Email Phone(Required)Email(Required) Policy #(Required)Property Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Loss(Required) MM slash DD slash YYYY Cause of the Damage(Required)Damages to (our Insured's Property)Roof(Required) Yes No Window(s)(Required) Yes No Siding(Required) Yes No Outbuilding(s)(Required) Yes No Fence(s)(Required) Yes No Personal Property(Required) Yes No Other?Injuries?(Required) Yes No Injury Details(Required)Who Was Injured?(Required)Authorities Called(Required) Yes No Who?(Required)Case #(Required)Any Repairs Done?(Required) Yes No What?(Required)Who Completed?(Required)Costs?(Required)Line BreakMortgage Company(Required)Loan #(Required)Contractor Selected?(Required) Yes No Who?(Required)Contact Info(Required)Confirmation of My ResponsibilitiesStop Damage Instructions(Required) I acknowledge it is my responsibility to take any action needed to stop further damage.(Required)Receipt & Picture Instructions(Required) I acknowledge it is my responsibility to save all receipts and take pictures prior to having repairs done.(Required)Estimate & Repair Instructions(Required) I acknowledge it is my responsibility to call repair company to start estimates on having repairs made.(Required)Mortgage Company Instructions(Required) I acknowledge it is my responsibility to call my mortgage company to find out their process.(Required)Recoverable Depreciation(Required) I acknowledge it is my responsibility to call my insurance agent to be informed about recoverable depreciation.(Required)Next Steps Instructions(Required) I acknowledge it is my responsibility to call my insurance agent to be informed of explanation of next steps.(Required) Δ
