Property Damage

"*" indicates required fields

(No Auto)

Please complete all fields below and be as specific as possible

Report prepared by*

Position*

Date*

Building Name*

Building Address*

#, Street, City, Zip

Type of Property Damage*

Pick one!

Type of Incident*

Pick one!

If Other, please specify

Incident Date*

Incident Time

List all tenants whose property was damaged. Use separate piece of paper if necessary.

Tenant Name

Tenant #1

Apt #

Tenant #1

Phone #

Tenant #1

Tenant Name

Tenant #2

Apt #

Tenant #2

Phone #

Tenant #2

Tenant Name

Tenant #3

Apt #

Tenant #3

Phone #

Tenant #3

Tenant Name

Tenant #4

Apt #

Tenant #4

Phone #

Tenant #4

Tenant Name

Tenant #5

Apt #

Tenant #5

Phone #

Tenant #5

Describe what caused the incident*

Describe extent of damage*

Describe property damaged*

Give name and positions of emergency personel on the scene*

For example: Fire Dept, Police Dept, Con Ed, etc

Videos or Photos/Taken*

Pick one!

If yes, how many?

File

Max. file size: 50 MB.

Photo(s)

Drop files here or

Max. file size: 50 MB.

Comments

more details

Property Damage

(No Auto)

Please complete all fields below and be as specific as possible

List all tenants whose property was damaged. Use separate piece of paper if necessary.

This form to be emailed to the Claims DL