INSURANCE CARRIER (INSURER) INFORMATION

POLICYHOLDER'S (INSURED) INFORMATION
Full Name(s)*
Phone*
Email*
example@example.com
Loss Address*
Example: 123 Street Dr. City , State, Zip
Primary Address if Different than Loss Address
Example: 123 Street Dr. City , State, Zip
Date of Loss or Discovery

MonthDayYear
Description of Loss (Type "Storm damage" if wind/hail claim)
INSURANCE CARRIER (INSURER) INFORMATION
Insurance Carrier(s) Name
Policy Number
Claim Number
Insured: By signing this agreement, the insured hereby authorizes KSA SOLUTIONS LLC to initiate and maintain communication with the insurer and its representatives on behalf of the insured as the insured's representative.
Date

MonthDayYear
Insured Signature*

Clear
Insured's Printed Name*
Date

MonthDayYear
Second Insured Signature

Clear
Second Insured's Printed Name
Limited Power of Attorney: I (the "Principal") hereby make, constitute, and appoint KSA SOLUTIONS LLC. to be my true and lawful "Attorney in Fact"
Principal Name (Print)
Principal's Signature

Clear
Date

MonthDayYear
Should be Empty: