Name:
Address:	Street City                                                          State          Zip
E-mail Address:
Daytime Phone:
Home Phone:
Policy Number:
Contact Person: Who should the adjuster contact about repairs?	Name: Home phone: Daytime phone: Email address:
Authority Contacted:	Police/Fire Department: Report number:
Claim Information:	Date of loss: Location of claim: Cause of loss: Fire Hail Lightning Smoke Theft Vandalism Vehicle Water Wind Other--describe below Describe, if other cause of loss:
Describe Your Damages:
Emergency services needed:	Temporary Shelter Required? Yes  No Windows Need Boarding up? Yes  No Other:
Persons Injured:	Name Phone number: Nature of injuries: Cause of injuries:
Additional Information or Comments: