Property Damage Insurance Claim
Property Damage Insurance Claim
Policyholder Information
|
Name |
[Your Name] |
|---|---|
|
Policy Number |
ABC123456 |
|
|
[Your Email] |
Incident Information
Date of Incident: October 10, 2053
Type of Damage: Water Damage
Location of Damage: Basement
Description of the Incident
On the morning of October 10, 2053, heavy rainfall resulted in the flooding of the basement. The water infiltrated through the basement windows, causing significant damage to the flooring, walls, and insulation. Additionally, personal belongings stored in the basement were affected, including furniture, electronics, and various household items.
Damage Assessment
|
Item |
Description |
Approximate Value |
|---|---|---|
|
Flooring |
Damaged laminate flooring |
$3,000.00 |
|
Walls & Insulation |
Water-damaged drywall and insulation |
$2,500.00 |
|
Furniture |
Soggy and stained couches and chairs |
$1,200.00 |
|
Electronics |
Water-damaged television and game console |
$1,000.00 |
|
Household Items |
Various damaged items including books, clothing, and decorations |
$800.00 |
Supporting Documentation
-
Photographs of the damage
-
Receipts for damaged items
-
Repair estimates from contractors
-
Police report (if applicable)
Claimant's Statement
I, [Your Name], certify that the information provided in this claim form is accurate to the best of my knowledge. I understand that any false statement or misrepresentation in the submission of this claim may lead to the denial of the claim and/or policy cancellation.
[Your Name]
[Date Signed]
[[Insurance Representative's Name]
[Date Signed]
