Todays Date
-
Month
-
Day
Year
Date
1st Named Insured
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First Name
Last Name
1st Named Insured Email
example@example.com
1st Named Insured Ph#
Please enter a valid phone number.
2nd Named Insured
*
First Name
Last Name
2nd Named Insured Email
example@example.com
2nd Named Insured Ph#
Please enter a valid phone number.
Insured Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Your Mailing Address Different than the Insured Address?
Yes
No
Mailing Address if Different than Insured Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Possible Cause of Loss?
Please Select
Pipe Burst
Water Damage
Reasonable Repairs
Debris Removal
Fungi, Mold, Bacteria
Wind Damage
Hail Damage
Collision
Weight of Ice and Snow
Collapse
Fire Loss
Electrical
Plumbing
Roof Damage
Flooring
Exterior
Other
5. Water damage from burst pipes.
6. Water damage from leaking roofs.
7. Freezing damage (e.g., frozen pipes).
8. Flooding (requires separate flood insurance).
9. Mold caused by water damage.
10. Theft or burglary.
11. Vandalism or malicious mischief.
12. Tree damage (e.g., falling branches on roofs or vehicles).
13. Smoke damage from nearby fires.
14. Appliance leaks (e.g., washing machines, dishwashers).
15. Sewer backup or sump pump failure (may require additional coverage).
16. Roof damage from heavy snow or ice dams.
17. Damage from flying debris during storms.
18. Structural collapse due to snow weight or other forces.
19. Power surge damage to electronics or appliances.
20. Accidental glass breakage (e.g., windows, doors).
21. Damage caused by pests like termites or rodents (often excluded but claimed).
22. Damage from fallen utility poles or wires on the property.
23. Vehicle impact on the home (e.g., car crashes into garage).
24. Damage to fences, sheds, or detached structures during storms.
25. Loss of personal property due to fire or theft (e.g., jewelry, electronics).
26. Liability claims for dog bites on the property.
27. Liability claims for injuries to guests (e.g., slips and falls).
28. Medical payments for injuries sustained by visitors on your property.
29. Damage caused by HVAC system malfunctions (e.g., water heater leaks).
30. Accidental discharge from sprinkler systems.
Assumed Date of Loss
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Month
-
Day
Year
If unsure, list time contractor observed loss.
Date Confirmed by Contractor?
-
Month
-
Day
Year
If unsure, list time contractor observed loss.
Approximate Age of Home?
*
Please Select
My home is about 0-2 years old
My home is about 3-5 years old
My home is about 5-10years old
My home is about 10-20 years old
My home is about 20-30 years old
My home is about 30-40 years old
My home is about 50-70 years old
My home is about 70-100 years old
My home is over 100 years old
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EXTERIOR
Statistics and Condition
Exterior
Roof System
ROOF: existing material on the roof
Please Select
20, 25, or 30 year Asphalt shingles
Aluminum or Steel Metal roofing
Concrete tiles, Slate tiles, or, Clay Tiles
Wood shakes, or Wood shingles
Synthetic roofing (slate or composite shingles), or Rubber roofing
Built-up roofing (BUR), or TPO (Thermoplastic Olefin) roofing
No roofing project!
ROOF: age of the roof
Please Select
1-5 years
5-10 years
10-15 years
15-20 years
20-25 years
Over 30 years
ROOF: pitch to the roof
Please Select
Flat Roof: 0° pitch
Low Slope Roof: 2° to 10° pitch
Conventional Slope Roof: 15° to 30° pitch
Steep Slope Roof: 30° to 45° pitch
Very Steep Slope Roof: 45° to 60° pitch
Mansard Roof: Combination of steep and flat sections
Gambrel Roof: Steep pitch on the upper section, flatter pitch on the lower section
Hip Roof: Sloping on all sides
Shed Roof: Single slope, often seen on sheds or lean-tos
Butterfly Roof: V-shaped roof with two slopes meeting in the middle
ROOF: projected new material to be put on that makes sense
Please Select
1. Asphalt shingles
2. Metal roofing
3. Clay tiles
4. Concrete tiles
5. Wood shakes
6. Wood shingles
7. Slate
8. Synthetic roofing (slate or composite shingles)
9. Rubber roofing
10. Built-up roofing (BUR)
11. TPO (Thermoplastic Olefin) roofing
MEASUREMENTS: Do you have software generated measurements of the roof and structure in a PDF file?
Yes
No
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MEASUREMENTS: file upload
*
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ROOF: condition description
*
Negative Observation: Based on visual inspection and photographic documentation, I—or a licensed contractor have identified roof conditions that appear to warrant corrective action. The observed deficiencies may compromise structural integrity or weatherproofing and should be evaluated for policy-covered repair or replacement.
Positive Observation: The roof is in fair to good condition.
No claim regarding the roof.
Other
Roof System Comments
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ROOF: images are current
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EXTERIOR
Siding Protection
SIDING: condition description
*
Negative Observation: I've observed the siding, taking pictures to document its damaged state.
Positive Observation: I've observed the siding, taking pictures to document its good state.
There is no claim regarding the siding.
Other
Siding System Comments
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SIDING: images are current
SIDING
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EXTERIOR
Windows and Doors
WINDOWS & DOORS: condition description
*
Negative Observation: I've taken images of windows and doors, noting their deteriorated condition for reference.
Positive Observation: I've taken images of windows and doors, noting their good condition for future reference.
There is no claim regarding the windows or doors.
Other
Windows & Doors Comments
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WINDOWS & DOORS
WINDOWS & DOORS
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EXTERIOR
Gutter System
GUTTERS & DOWNSPOUTS: condition description
*
Negative Observation: I've photographed the gutters and downspouts, making negative observations about their current damaged state.
Positive Observation: I've photographed the gutters and downspouts, making positive observations about their current state.
There is no claim regarding the gutters or downspouts.
Other
Gutter System Comments
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GUTTERS & DOWNSPOUTS
GUTTERS & DOWNSPOUTS
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EXTERIOR
Chimney System
CHIMNEY COMPONENTS: condition description
*
Negative Observation: I've taken pictures of the chimney, making a visual record of its damaged condition.
Positive Observation: I've taken pictures of the chimney, making a visual record of its excellent condition.
There is no claim regarding the chimney components.
Other
Chimney System Comments
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CHIMNEY COMPONENTS
CHIMNEY COMPONENTS
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EXTERIOR
Decking/Patio System
DECK & PATIO: condition description
*
Negative Observation: I've observed the deck or patio, capturing its current state in photographs, and it looks damaged.
Positive Observation: I've observed the deck or patio, capturing its current state in photographs, and it looks good.
There is no claim regarding the deck or patio.
Other
Deck/Patio Comments
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DECK & PATIO
DECK & PATIO
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EXTERIOR
Dividers and Wall Systems
DIVIDER/WALL: condition description
*
Negative Observation: I've documented the fences, noting their appearance with observed damage.
Positive Observation: I've documented the fences, noting their appearance without any observed damage, all in good shape.
There is no claim regarding the fence or divider.
Other
Divider/Wall Comments
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DIVIDER/WALL
FENCES & DIVIDERS
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EXTERIOR
Garage Door System
GARAGE DOORS: condition description
*
Negative Observation: I've taken images of the garage door, documenting its current damaged condition.
Positive Observation: I've taken images of the garage door, documenting its current good condition.
There is no claim regarding the garage doors.
Other
Garage Door Comments
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GARAGE DOORS: images
GARAGE DOORS
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EXTERIOR
Detached Property
DETACHED PROPERTY: condition description
*
Negative Observation: I've observed the unattached building, taking pictures to document its present state, and it looks damaged.
Positive Observation: I've observed the unattached building, taking pictures to document its present state, and it looks well-maintained.
There is no claim regarding the detached property.
Other
Detached Property Comments
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DETACHED PROPERTY: images
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EXTERIOR
Neighborhood
NEIGHBORHOOD: condition description
*
Negative Observation: I've documented surrounding neighbor's homes, capturing their current appearance with specific damages observed.
Positive Observation: I've documented surrounding neighbor's homes, capturing their current appearance without any specific damages, all in good condition.
Other
Neighborhood Comments
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NEIGHBORHOOD: images
NEIGHBORHOOD
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INNER WALLS
The Unseen or Obscure.
OBSCURE: checked closets, ceilings, attics, crawlspace or not readily visible areas
*
I have not checked all four of these internal areas: walls, ceilings, attic, or crawl space for damages.
In response to the question about the internal areas—walls, ceilings, attic, or crawl space—no damages were observed inside these spaces by me or my contractor. Based on my opinion, there is no indication of internal damage in these areas.
Yes, I believe there may be additional damage on the inner walls of the structure.
Other
OBSCURE: Discussing the repercussions of the recent incident and the resulting losses. The intensity of the event has inflicted significant harm to the property, resulting in various damages that require immediate attention and resolution. This data is essential for our public adjuster to comprehensively grasp the situation.
Potential Hidden Water Damage: Damage to walls or flooring that might not be immediately visible.
Undetected Electrical System Compromises: Wiring or electrical component issues within walls that may not be apparent.
Possible Insulation Deterioration: Damage to insulation affecting energy efficiency, not easily noticeable.
Concerns with Structural Integrity: Hidden damage to structural components that could impact stability.
Appliance Malfunctions: Damages to appliances that may only become apparent during use.
Risk of Pest Infestations: Attraction of pests due to water damage, not easily visible initially.
Concealed Mold Growth: Moisture-induced mold growth in hidden areas, affecting indoor air quality.
Underfloor Issues: Flooring hiding potential damage to the subfloor.
Hidden HVAC System Compromises: Damage to the HVAC system not immediately evident.
Possible Undetected Leaks: Leaks in plumbing or the roof that may not be visible upon casual inspection.
OBSCURE: reports to upload
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INTERIOR CONDITION
Visible Areas in the Home
Interior Damage: areas that have been visibly impacted, either observed directly or verified by a contractor or specialist..
*
WATER DAMAGE: I have discovered water damage in my home, and it is essential to address the water intrusion and damage caused by storms, leaks, pipe-bursts, or backups. Taking immediate action is crucial to prevent further deterioration and protect my property.
FUNGI: I have identified what looks like mold growth in my home, and it is imperative to remove it to ensure a healthy and safe living environment. Mold remediation may be necessary to eliminate any potential health risks associated with its presence in my house.
ASBESTOS: I have found asbestos-containing materials in my property, and it is important to remove or encapsulate them to eliminate any health risks. Asbestos abatement is necessary to ensure my safety and well-being in my own home.
LEAD: There is lead-based paint in my home, and it needs to be addressed to prevent lead poisoning. Removing or containing the lead paint is essential for my well-being, especially if I have children living with me.
RADON: I have discovered high levels of radon gas in my home, and it is crucial to mitigate it to safeguard against potential health hazards. Reducing radon gas levels is necessary to ensure my safety and the well-being of everyone living in my house.
ATTIC: The roof and attic of my home have been damaged, and I need to repair them to maintain the integrity of the roof and prevent any leaks. Fixing the damaged roofing materials promptly is vital to prevent further damage to my own property.
MITIGATION: I have noticed damaged interior walls in my home, likely caused by water leaks, mold, or other issues. It is important to repair these walls to restore their integrity and improve the overall condition of my house.
FLOORING: The flooring in my home has been damaged, whether it's wood, carpet, or tiles, and I need to repair or replace it. Restoring the damaged flooring is necessary to enhance the aesthetics and functionality of my own property.
PLUMBING: The plumbing system in my house has been damaged or is leaking, and it needs immediate repair. Fixing the damaged or leaking pipes, faucets, or plumbing fixtures is crucial to ensure the proper functioning of the plumbing system in my home.
ELECTRICAL: There are electrical issues in my property, such as faulty wiring or damaged outlets, and they need to be addressed. Repairing these electrical problems is necessary to ensure the safety and functionality of the electrical system in my own home.
HVAC: The heating, ventilation, and air conditioning (HVAC) system in my home has been damaged and requires repair or replacement. Restoring the HVAC system is essential for maintaining a comfortable and healthy living environment in my own house.
CIELING: I have noticed damaged ceilings in my home, likely caused by water leaks or other issues. Repairing or replacing the damaged ceilings is necessary to restore the overall aesthetics and structural integrity of my own property.
FIREPLACE: The insulation in my home has been damaged, and I need to improve or replace it for energy efficiency and comfort. Enhancing or replacing the damaged insulation is crucial for maintaining a comfortable indoor environment in my own house.
FIRE: My property has been damaged by fire, and it is important to address the fire damage promptly. This includes removing smoke and soot, as well as conducting structural repairs to restore my property to its pre-fire condition.
PAINT: I need to repaint the damaged or affected areas of my home to restore its aesthetics. Interior painting is necessary to revitalize my property and create a fresh and appealing atmosphere in my own house.
WINDOWS: The windows and doors in my house have been damaged and need to be repaired or replaced. Fixing or replacing these damaged windows and doors is important for insulation and security purposes in my own home.
CABINETS: The cabinetry, countertops, and fixtures in my property have been damaged and require repair or replacement. Restoring or replacing these damaged elements is necessary to ensure functionality and improve the overall appearance of my own house.
STRUCTURE: There is damage to the structural integrity of my building, such as beams or load-bearing walls, and it needs to be addressed. Conducting structural repairs is crucial for the long-term stability and safety of my own property.
MOISTURE: I need to implement measures to control moisture levels in my property to prevent future damage. Moisture control is necessary to protect my property from potential issues and maintain its integrity.
ODORS: There are unpleasant and ensuing odors in my home caused by water damage, mold, or fire, and they need to be eliminated. Removing these odors is essential for creating a clean and fresh living environment in my own house.
LIGHTING: The emergency lighting systems in my property has been compromised by the cause of cause of loss. Safety during power outages cannot commence. Emergency lighting installation ensures my well-being during unforeseen circumstances in my own home and I will need to seek insurance recovery for it.
SECURITY: The security system in my home has been damaged and needs repair or replacement. Restoring or replacing the damaged security system is crucial to ensure the security of my property.
VENTILATION: I need to improve the ventilation and air quality in my property through repairs or restoration. Restoring ventilation and air quality is priority.
NO INTERIOR ISSUES!
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Interior Images
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Accountability
Declarations
Signature
ACCOUNTABILITY: acknowledgement agreement
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All the above has been completed to the best of my ability: Thank you for transparently and accurately providing the necessary information and assisting with my claim..
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