TEST TEST Property Claim Date InformationDate of Loss(Required) MM slash DD slash YYYY Date Reported to Agency(Required) MM slash DD slash YYYY Time Reported to Agency(Required) Hours : Minutes AM/PM AM PM AM/PM Client & Claim InformationName of Insured(Required) First Last Policy Number(Required) Insured Email address(Required) Contact Person(Required) Phone #(Required)Work Phone #Location of Damaged Property(Required) Street Address City Description of Loss & Damage(Required)Estimated Damages(Required)Under $10,000$10,000-$50,000$50,000-$100,000Over $100,000Triage(Required)Blue / Tier 1 – VULNERABLE – special attention required for individuals with specific needs (ie: age or disability)Green / Tier 2 – MINOR – damage does not affect normal operations of household/business/farmYellow / Tier 3 – SIGNIFICANT – damage with potential to cause further damage to structureRed / Tier 4 – MAJOR – damage disrupts household/business/farm operations and uninhabitableBlack / Tier 5 – CRITICAL – immediate intervention required (ie: major fire/risk of structural collapse)Policy Items InvolvedItem #1Peril Involved(Required)Water – SurfaceWater – GroundWater – Sewer / Septic BackupWater – Sump Pit OverloadWater – Sump Pump FailureWater – Escape Plumbing LineWater – Overflow Plumbing ApplianceFire – Wood / Solid Fuel HeatingFire – ElectricalFire – SmokingFire – Portable HeaterFire – Spread From Third PartyFire – Careless Use of Candles or MatchesFire – Improper Storage of Handling of Chemicals or FuelsFire – Cooking Operations: GreaseFire – Spread from an AutomobileFire – Arson or SuspectedFire – OtherSmokeLighteningPower InterruptionWind – Special (TV Aerial)WindImpactOverturn, TransportationFalling ObjectsEarthquakeLivestockTheftVandalismCropLiabilityMysterious DisappearanceFraudHome Systems ProtectionIdentity TheftGlass BreakageFreezer FailureCollapseMachineryPollutionFarmers AccidentOtherItem(Required) Description of Item(Required) Amount of Insurance(Required) Deductible $(Required) Item #2Item Description of Item Amount of Insurance Item #3Item Description of Item Amount of Insurance Office & Agent InformationPolice Department(Required) Occurance #(Required) Reporting Person(Required) Reporting Agency(Required) Broker InformationBroker Email Address(Required) Supporting Images Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB, Max. files: 5. Maximum file size – 5 mega bytes. EmailThis field is for validation purposes and should be left unchanged.