File a Property Claim Submit an insurance claim on your church property File a Property Claim Church Information Name of Church * Address * Address Address Line 1 Address Line 1 Address Line 2 (Optional) Address Line 2 (Optional) City City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Contact Information This is who the insurance company will contact regarding the claim Name * Phone * Email * Claim Information Type of Claim * Fire Water Theft Other Type of Claim Date of loss * If date of loss is unknown, enter the date of discovery Time (if known) 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM Description/Nature of Accident/Incident * Fire Was the fire department called * Yes No Are any portions of the property left exposed due to the fire (classrooms or kitchen with missing walls, etc) * Yes No Water Has the water been removed? * Yes No Does the church have a sump pump? * Yes No Theft Description of stolen/damaged property * Include known/applicable model/serial numbers, approximate age and replacement value Name of investigating organization * Address of investigating organization * Address of investigating organization Address Line 1 Address Line 1 Address Line 2 (Optional) Address Line 2 (Optional) City City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Phone number of investigating organization * Name of contact person (if applicable) Date reported * Report number * Submit
