Berends Hendricks Stuit Insurance Agency, Inc. ::: Homeowners Insurance Claim

Homeowners Insurance Claim

Please Note: You will need approval from your insurance carrier to begin repairs. If you have not been contacted within 48 hours, please call our office for assistance.

Policyholder Information

Name:

Date:

Phone:

Ext

Email:

General Information

Date of Loss:

Location of Loss:

Fire Department Name:

Report Number:

Property Damage Information

Description of Accident/Loss:

Describe Damage:

Probable Amount of Loss:

Emergency Repairs or Contractor Information(if used)

Name:

Adress:

City, State, Zip:

Work Phone:

Witness 1

Name:

Address:

City, State, Zip:

Home Phone:

Work Phone

Ext:

Witness 2

Name:

Address:

City, State, Zip:

Home Phone:

Work Phone:

Ext:

Comments

Please provide any additional information you feel may be helpful: