Property Claim Form

Inter/National Fraternity/Sorority*

Chapter Name*

Chapter Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Policy Number

Loss Information

Date of Loss

Time of Loss (HH:MM:Period of Day)

Location of Loss

Type

(i.e. wind, hail, theft, etc.)

Description

Extent of Damage

Main Contact Information

Name*

First Last

Title

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

Home Phone

Cell Phone

Mortgage/Loss Payee

Secondary Contact Information

Name

First Last

Title

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

Home Phone

Cell Phone

Which contact will provide access to the house?

Main Contact
Secondary Contact

Was this reported to the Police Department?

Yes
No

Was this reported to the Fire Department?

Yes
No

Name of Investigating Agency and Case #

Were emergency repairs required?

Yes
No

If yes, provide the contractor information below

Name of Contractor

Contact Name

Work Phone

Cell Phone

Do you have a contractor selected to complete the repairs?

Yes
No

Name of Contractor

Contact Name

First Last

Contact Number

Estimate Amount

Additional Remarks

Name of person completing report

Date Report Completed

File Upload

Drop files here or

Upload pictures, invoices, etc.

Property Claim Form

Loss Information

Main Contact Information

Secondary Contact Information

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