subject_line
Property Claim Form
Notice of Damage or Theft to Property and/or Equipment
Insured Name:
*
Insured Address:
*
Date of incident:
*
+
Who discovered the loss?
*
Phone Number:
*
Date Discovered:
*
+
What damage was done to the premises?
*
Reported to Authority?
*
Yes
No
Authority Report to:
*
Case Number:
*
Description of loss:
*
Contact Name:
*
Contact Email:
*
Contact Phone Number:
*
How many items do you need to make a claim for?
*
1-5
6-10
11-20
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
The following is a schedule of the articles known to be damaged and/or stolen:
Please list below:
Item Number:
Please list below:
Description of Property:
Please list below:
When was the item last seen? Location?
Please list below:
When was the item purchased? Where?
Please list below:
Actual cost of article:
Please list below:
Please upload any other documents such as police reports, lawsuits, receipts, photos etc…
1. File Upload
2. File Upload
Attach a maximum of 10 files to each file upload field. A zip file containing multiple files counts as 1.
If you are having any issues uploading certain files above, please email your documents to:
claims@ib-tx.com
Estimated Property Loss:
*
Actual Amount of Cash:
*
Estimated Damage to Premises:
*
Total Estimated Loss:
*
Additional Information: