Complete address of where damage occurred, include Bldg and Unit number if applicable

Describe how damage occurred - i.e. broken window, hole in roof, lightening, etc.

Describe all property that was damaged, type of damage and where damaged property is. Be specific - i.e. drywall in master bedroom closet is wet and wall paper is coming off.

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For Insurance Department Use Only

Date Received______by________Acknowledgement sent to resident____________
Name of insurance company_______________________________
Date called in to insurance company____________
Name of insurance company personnel taking claim_____________
Claim number if available with submission____________________
Claim submitted via phone______ fax_______ email________
Data Entry Date_______________
Cc to Property Manager________________________________