| Your
Name: |
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| Contact
Person: |
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| Contact
Phone Number: |
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| Alternate
Phone Number: |
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| E-mail
Address: |
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| Confirm
E-mail Address: |
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How
did you hear about us: |
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| Insured
First Name: |
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| Last
Name: |
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| Policy
Number: |
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| Property
Address: |
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| City: |
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| State/Province: |
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| Country: |
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| Zip
Code: |
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| Mailing
Address: |
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| City: |
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| State/Province: |
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| Country: |
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| Zip
Code: |
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| Loss
Information: |
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| Date
of Loss: |
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| Location
of Loss |
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| Time
Loss Was Detected: |
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| Storm
Name: |
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| Type
of Structure: |
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| Type
of Loss: |
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| Is
your home inhabitable? |
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| Do
you have electrical power? |
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| Do
you have potable running water? |
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| What
areas are damaged? |
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| If
Other, please describe: |
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| Description
of Loss: |
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| Did
your home suffer any flooding or storm surge damage? |
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| Flood
Carrier: |
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| Flood
Carrier Policy Number: |
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| Did
you have a policy with Citizen's Property and Casualty? |
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| Citizen's
Policy Number: |
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| |
| 1st
Mortgage Company Name: |
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| 1st
Mortgage Company Loan No.: |
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| 2nd
Mortgage Company Name: |
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| 2nd
Mortgage Company Loan No.: |
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