Date (required) Example Format: 2016-05-30

Insured Name (required)

Loss Address (required)

Major Intersection (required)

Contact Phone # (required)

Email address (required)

Insurance Company (required)

Claim #

Deductible Amount

1. Have you inspected the home?
Yes No 

2. In your opinion, is the home habitable?
Yes No 
If no, what are the main areas of concern:

3. What is the approximate age of the home?

4. Are there any of the following residents that live in the home, how many?
Children under the age of 2:
Elderly:
Person suffering from chronic illness:

5. If you were to rate the severity of the damage to your home, how would you rate it:

Please provide a brief description of the damage and why you have provided the rating as indicated above.

Policyholder Signature (required, click or tap to draw your signature)