Easy Claim Form - Insurious

Required *

Required *

Policy & Contact Information

Policy & Contact Information

Policy Holder Name *

Policy Number *

Contact Name *

Email Address *

Phone *

Loss Estimate & Details

Loss Estimate & Details

DATE & TIME OF LOSS

Date of Loss *

Time of Loss

Hours

Minutes

LOCATION OF LOSS

Addresss *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

ESTIMATE AMOUNT OF LOSS

Estimate Amount *

USD

LOSS DETAILS

Damage Description *0 / 180

Additional Details0 / 180

Owned Equipment Over $5K?*

Owned Equipment Over $5K *YesNo

Rented Equipment?

Rented Equipment?*

Rented Equipment? *YesNo

Police Report

Police Report

Police Report Submitted?

Report Submitted?YesNo

Police Report Number

Name of Police Department

Read & Sign

Read & Sign

Disclosure

By completing and signing this form, I verify that all the information provided is true and accurate to the best of my knowledge. I confirm my understanding that in the event of a loss or theft, a police report is required. I am permitted to withdraw a claim prior to settlement. If a claim is settled with payment, I am aware that I have to disclose the claim in all future insurance applications. Furthermore, settled or open claims may affect future insurance rates or eligibility. Failure to disclose a settled or existing open claim can cause my coverage to be null and void. I also understand that insurance fraud is a crime under state and federal law and it can result in jail time and large penalty fines.

Signature & Date

Enter your full name, first name and last name as it appears on your policy.

Signature *

Sign Date *