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Home & Property Claim Data Collection Form
Claim Reported by:
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Primary Contact Name:
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Primary Contact Phone:
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Primary Contact Email:
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Insured Name / Policy Holders Name
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Type of Property / Dwelling (Home / Primary / Secondary / Seasonal)
Dwelling / Property Address:
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Date of Loss
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Date Reported
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Approximate Time of Claim
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Insurance Company & Policy Number (If Known)
Description of Incident / What Happened / Please Provide as Much Detail as Possible
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Description of Damage / What Was Damaged
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Other Party's Information (If Known Please Provide Name / Phone Number / Address / Any Other Known Information):
Injuries (If Any):
Best Point of Contact (Please Provide as Much Contact Information as Possible)
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Additional Notes / Comments for the Insurance Agent