INSURED (Your First and Last Name)
*
ADDRESS
*
HAIL EVENT (Type an X if your home was damaged by hail.)
WIND EVENT (Type an X if your home was damaged by wind.)
OTHER (Specify Hail & Wind or Tornado or other.)
LOSS DATE (Date of storm)
/
Month
/
Day
Year
Date
INSURANCE CARRIER
*
POLICY NUMBER
CLAIM NUMBER (if available)
INSURED SIGNATURE
*
TODAY'S DATE
/
Month
/
Day
Year
Date
HOME PHONE # (or primary phone #)
*
WORK/CELL PHONE (or secondary phone #)
EMAIL
example@example.com
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