Claims Form
Personal Information
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Storage Facility Information
Address
City, State, Zip
Manager Name
Email Address
Facility Phone
Claim Information
Date Discovered
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Loss
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Was the facility manager notified?
Has a claim been filed with insurance?
Unit #
Name of Manager Notified
If burglary, has law enforcement been notified?
Has police been notified?
If Yes, name of Law Enforcement Agency:
Case #
Describe Loss (*Burglary/Vandalism Loss requires a Police Report & Pictures/Documentation by Management Identifying Forcible Entry)
Include pictures of damage
Browse Files
Cancel
of
Inventory
Please include item description, year purchased, cost of new (must include all 3 answers):
Amount for replacement of same or similar:
Please verify that you are human
*
Submit
Should be Empty: