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3. 
5. First Name*
6. Last Name*
8. Phone Number*
9. Email Address*
11. Additional Claimant (First Name)
12. Additional Claimant (Last Name)
14. Incident Address*
16. City*
17. State*
18. Zip Code*
20. Mailing Address (If different from incident address)
22. City
23. State
24. Zip Code
26. Date of Incident/Injury*
    Date of Incident/Injury
28. Description of Incident/Injury*
30. Attachment(s)*

    Provide an itemized list of damages and attach to this claim form as a Word document. Please include:

    • Personal Property Damage (e.g. clothing, electronics, appliances, furniture, etc.)
      • Type of item(s)
      • Description of item(s) including brand name, model, etc.
      • Approximate age of item at time of incident/injury.
      • Original cost (amount paid for item)
      • Photos
      • Receipts, if available.
    • Structural Damage (e.g. drywall, paneling, flooring, carpet, furnace, water heater, etc.)
      • Description of item
      • Cost to repair/replace damage
      • Estimate(s), invoice(s) and receipt(s) related to structural damage repairs
      • Photos
    • Costs incurred to hire a professional cleaning contractor
      • Name of licensed professional cleaning contractor
      • Cost of work completed
      • Itemized estimate/invoice - description of the work performed
32. Signature*
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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit Submit and Print

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