Retail Insurance Claim
Retail Insurance Claim
1. Policyholder Information
|
Name |
[Your Name] |
|
Policy Number: |
038-278-09 |
|
Email: |
[Your Email] |
2. Incident Information
|
Date of Incident: |
July 15, 2050 |
|
Time of Incident: |
3:45 PM |
|
Location of Incident: |
123 Main Street, Springfield, IL 62701 |
|
Description of Incident: |
On July 15, 2050, around 3:45 PM, a severe thunderstorm hit ABC Retail Store, causing significant water damage to inventory and fixtures due to a roof leak and flooding in the backroom. |
3. Itemized List of Losses or Damages
|
Item Description |
Quantity |
Unit Cost |
Total Cost |
|---|---|---|---|
|
Flood-damaged merchandise |
50 items |
$40.00 |
$2,000.00 |
|
Shelving units |
10 units |
$150.00 |
$1,500.00 |
|
Electrical equipment |
5 items |
$80.00 |
$400.00 |
|
Flooring repairs |
N/A |
N/A |
$800.00 |
4. Supporting Documentation
Please attach the following documentation to support your claim:
-
Photographs of the damaged items or property
-
Receipts or proof of purchase for the claimed items
-
Police report, if applicable
-
Any other relevant documentation
5. Declaration
I hereby declare that all information provided in this claim form is accurate and complete to the best of my knowledge. I understand that any false or misleading information may result in the denial of my claim and potential legal action.
[Your Name]
[Date]
