Tenant Insurance Claim
Tenant Insurance Claim
1. Claimant Information
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Name: [Your Name]
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Email: [Your Email]
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Policy Number: 942-590-88
2. Incident Information
Please provide detailed information about the incident.
|
Field |
Details |
|---|---|
|
Date of Incident |
July 25, 2050 |
|
Time of Incident |
Approximately 2:00 PM |
|
Location |
456 Maple Avenue, Apt. 12C, Springfield, IL 62704 |
|
Description |
On July 25, 2050, a burst pipe in the upstairs apartment caused a water leak that damaged my living room and bedroom flooring and furniture. I discovered it at 4:00 PM when I came home. |
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Supporting Documents |
Attached are photos showing the damage, a repair estimate from Springfield Restoration Services, and a copy of my lease agreement. |
3. Personal Property Damage
Please provide a detailed list of items that were damaged, including the following information for each item:
|
Item Description |
Purchase Date |
Purchase Price |
Estimated Repair/Replacement Cost |
|---|---|---|---|
|
Living Room Sofa |
January 10, 2050 |
$800 |
$1,000 (Replacement) |
|
Wooden Coffee Table |
March 15, 2050 |
$200 |
$250 (Replacement) |
|
Bedroom Rug |
June 5, 2050 |
$150 |
$200 (Replacement) |
|
Flat-Screen TV |
November 20, 2050 |
$600 |
$650 (Replacement) |
|
Dining Set (Table + 4 Chairs) |
August 22, 2050 |
$500 |
$600 (Replacement) |
4. Attachments
Include any supporting documents:
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Photos of Damages
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Receipts/Estimates
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Police Report
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Communication Correspondence
5. Declaration
I, the undersigned, declare that the information provided is accurate to the best of my knowledge and that I have not withheld any material information relevant to this claim.
[Your Name]
[Date]
