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: