Storm Loss

Storm Loss Form

Claim Number: *

Policy Number: *

Insured(s): *

Date of loss: *

Urgency Level *Urgent (i.e. water in the home)High (i.e. insured waiting for response)Normal (i.e. insured out of town/not primary residence)

Leak Developed *

• Roof
• Wall
• Basement
• None

Additional Details:

Property Under Contract to Sell (Buy/Sell Agreement Attached) *

• Yes
• No

Closing Date:

Contractor or Body Shop Has Inspected (Attached Estimate) *

• Yes
• No

Client on Vacation *

• Yes
• No

Vacation Dates:

Re-Inspection (An estimate is required to start the process) *

• Yes
• No

Reason:

Rental Car *

• Yes
• No

Rental Car Dates:

Other (please explain):

Agent Number:

Staff Member Submitting Claim:

Submitter Email: *

Comments:

Relevant attachments:

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Website

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