Property Claim Form

Reporting Form

If your location has sustained property damage or business interruption, the following information is needed to report the claim:
Location Name
Address
City
State
Zip Code
Contact Name
Cell Phone
Email
example@example.com
Date of Loss

MonthDayYear
Date
Building Damaged?
Description of Loss
Contents Damaged?
Description of Loss
(Note: Please take picture of damage to both building and contents)
Take Photo
Loss of Power Date

MonthDayYear
Date
Power Back On Date

MonthDayYear
Date
Are you or your clients restricted from conducting business as a result of authorities not allowing travel to and from?
If yes what date did restrictions start and end

MonthDayYear
Date
What was purpose of restriction
Date you have been able to resume business

MonthDayYear
Date
If you have questions, please contact: Heyward Burnet @ (904)753-3155
Should be Empty: