Property Damage

(No Auto)

Please complete all fields below and be as specific as possible

Report prepared by*

Position*

Report Completed*

Date of Incident*

Building Name*

Building Address*

#, Street, City, Zip

Type of Property Damage*

Type of Incident*

If Other, please specify

List all tenants whose property was damaged. Use separate piece of paper if necessary.

Tenant Name

Tenant #1

Apt #

Tenant #1

Phone #

Tenant #1

Carrier

Tenant #1

Policy #

Tenant #1

Tenant Name

Tenant #2

Apt #

Tenant #2

Phone #

Tenant #2

Carrier

Tenant #2

Policy #

Tenant #2

Tenant Name

Tenant #3

Apt #

Tenant #3

Phone #

Tenant #3

Carrier

Tenant #3

Policy #

Tenant #3

Tenant Name

Tenant #4

Apt #

Tenant #4

Phone #

Tenant #4

Carrier

Tenant #4

Policy #

Tenant #4

Tenant Name

Tenant #5

Apt #

Tenant #5

Phone #

Tenant #5

Carrier

Tenant #5

Policy #

Tenant #5

Describe what caused the incident*

Describe extent of damage*

Describe property damaged*

Give name and positions of emergency personel on the scene*

For example: Fire Dept, Police Dept, Con Ed, etc

Videos or Photos/Taken*

If yes, how many?

File

Max. file size: 50 MB.

Photo(s)

Drop files here or

Max. file size: 50 MB.

Comments

more details

(No Auto)

Please complete all fields below and be as specific as possible

List all tenants whose property was damaged. Use separate piece of paper if necessary.

This form to be emailed to the Claims DL