Utilities Insurance Claim
I. Policyholder Information
Policyholder Name: | [Your Name] |
Policy Number: | 123456789 |
Contact Information: | [Your Email], (555) 123-4567 |
Address: | 123 Elm Street, Springfield, IL 62701 |
II. Incident Description
Date of Incident: July 25, 2054
Type of Utility Service Affected: Electricity
Duration of Service Disruption: 8 hours
Description of Incident:
On July 25, 2054, a severe thunderstorm caused a power outage in the Springfield area. The electricity supply was disrupted due to damage to the local power lines. The outage lasted for approximately 8 hours, during which time several electrical appliances in my home were damaged due to a power surge when the electricity was restored.
III. Damage Report
Item/Property Damaged | Description of Damage | Estimated Repair/Replacement Cost |
|---|
Refrigerator | Electrical components damaged | $800 |
Television | Screen and circuit board damaged | $600 |
Computer | Power supply and hard drive failure | $1,200 |
IV. Support Documentation
Attached Documents:
Utility Bill showing service disruption
Photographs of damaged property
Repair estimates or invoices
Any relevant correspondence with utility companies
V. Claim Statement
I hereby attest that all the information provided in this claim is accurate and comprehensive to the best of my knowledge. I request the insurance company to review my claim and provide the appropriate compensation for the losses incurred due to the utility service disruption.
VI. Signature
[Your Name]
[Date Signed]
Claim Templates @ Template.net
