File a Property Claim

Church Information

Name of Church *

Address *

Address

Address Line 1

Address Line 2 (Optional)

City

State

Zip

Contact Information

This is who the insurance company will contact regarding the claim

Name *

Phone *

Email *

Claim Information

Type of Claim * Type of Claim

Date of loss *

If date of loss is unknown, enter the date of discovery

Time (if known)

Description/Nature of Accident/Incident *

Fire

Was the fire department called *

Yes

No

Are any portions of the property left exposed due to the fire (classrooms or kitchen with missing walls, etc) *

Yes

No

Water

Has the water been removed? *

Yes

No

Does the church have a sump pump? *

Yes

No

Theft

Description of stolen/damaged property *

Include known/applicable model/serial numbers, approximate age and replacement value

Name of investigating organization *

Address of investigating organization *

Address of investigating organization

Address Line 1

Address Line 2 (Optional)

City

State

Zip

Phone number of investigating organization *

Name of contact person (if applicable)

Date reported *

Report number *