Retail Insurance Claim
1. Policyholder Information
Name | [Your Name] |
Policy Number: | 038-278-09 |
Email: | [Your Email] |
2. Incident Information
Date of Incident: | July 15, 2050 |
Time of Incident: | 3:45 PM |
Location of Incident: | 123 Main Street, Springfield, IL 62701 |
Description of Incident: | On July 15, 2050, around 3:45 PM, a severe thunderstorm hit ABC Retail Store, causing significant water damage to inventory and fixtures due to a roof leak and flooding in the backroom. |
3. Itemized List of Losses or Damages
Item Description | Quantity | Unit Cost | Total Cost |
|---|
Flood-damaged merchandise | 50 items | $40.00 | $2,000.00 |
Shelving units | 10 units | $150.00 | $1,500.00 |
Electrical equipment | 5 items | $80.00 | $400.00 |
Flooring repairs | N/A | N/A | $800.00 |
4. Supporting Documentation
Please attach the following documentation to support your claim:
Photographs of the damaged items or property
Receipts or proof of purchase for the claimed items
Police report, if applicable
Any other relevant documentation
5. Declaration
I hereby declare that all information provided in this claim form is accurate and complete to the best of my knowledge. I understand that any false or misleading information may result in the denial of my claim and potential legal action.
[Your Name]
[Date]
Insurance Claim Templates @ Template.net
