Berends, Hendricks, & Stuit Insurance Agency, Inc. :: Claims :: Personal Claims

Claims :: Personal Claims :: Homeowners Insurance Claim

Please note: You will need approval from your insurance carrier to begin repairs. If you have not been contacted within 48 hours, please call our office for assistance.

Contact Information
Name:
Date:
Daytime Phone Number:	Ext:
Email Address:

General Information
Date of Loss:
Location of Loss:
Authority Contacted:
Weather conditions on day of accident:

Property Damage Information
Description of Accident / Loss (What Happened):
Describe Damage:
Probable Amount of Loss:

Person responsible for damage
Name:
Address:
City, State, Zip:
Home Phone:
Work Phone:	Ext:

Witness 1
Name:
Address:
City, State, Zip:
Home Phone:
Work Phone:	Ext:

Witness 2
Name:
Address:
City, State, Zip:
Home Phone:
Work Phone:	Ext:

Comments
Please give us any additional information you feel may be helpful:
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