Tenant Insurance Claim
1. Claimant Information
2. Incident Information
Please provide detailed information about the incident.
Field | Details |
|---|
Date of Incident | July 25, 2050 |
Time of Incident | Approximately 2:00 PM |
Location | 456 Maple Avenue, Apt. 12C, Springfield, IL 62704 |
Description | On July 25, 2050, a burst pipe in the upstairs apartment caused a water leak that damaged my living room and bedroom flooring and furniture. I discovered it at 4:00 PM when I came home. |
Supporting Documents | Attached are photos showing the damage, a repair estimate from Springfield Restoration Services, and a copy of my lease agreement. |
3. Personal Property Damage
Please provide a detailed list of items that were damaged, including the following information for each item:
Item Description | Purchase Date | Purchase Price | Estimated Repair/Replacement Cost |
|---|
Living Room Sofa | January 10, 2050 | $800 | $1,000 (Replacement) |
Wooden Coffee Table | March 15, 2050 | $200 | $250 (Replacement) |
Bedroom Rug | June 5, 2050 | $150 | $200 (Replacement) |
Flat-Screen TV | November 20, 2050 | $600 | $650 (Replacement) |
Dining Set (Table + 4 Chairs) | August 22, 2050 | $500 | $600 (Replacement) |
4. Attachments
Include any supporting documents:
5. Declaration
I, the undersigned, declare that the information provided is accurate to the best of my knowledge and that I have not withheld any material information relevant to this claim.
[Your Name]
[Date]
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