Property Claim First Report Form

Claim Details
Name of Claimant *
Address of Claimant *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Liability Claim Information
Person to Contact for Claim *
Date of incident / injury: *

Month Day Year
Date
Location *
Authority Contacted: *
Please give a detailed description of the incident: *
Please describe any property damage (Type, Model, etc.): *
Estimated amount of loss: *
Where can property be seen by company adjuster? *
The original complaint letter and/or summons should be sent to our office immediately, including the original accompanying envelope.

If the damaged property was rented, please submit your form along with a copy of your rental contract.

insurance@filmemporium.com

Claim Details