Company Name (required) Contract Number (required) Claim Contact Name Claim Contact Phone Claim Contact Email Address Date of Loss Serial Number(S) (required) Replacement/Repair (required) Cause of Loss (Mark All That Apply) Fire: Fire Roof Leak: Roof Leak Tornado: Tornado Lightning Power Surge: Lightning Power Surge Pipe Leakage: Pipe Lea kage Vandalism:Vandalism Wind:Wind Theft: Theft Water Roof Leak: Water Roof Leak Flood: Flood Explosion:Explosion Elec. Failure/Disturbance:Elec. Failure/Disturbance Utility Interruption:Utility Interruption Other: Other Incident Detail Required Paperwork to Be Returned Vendor: Service Report: Service Report Police Report : Police Report . Replacement Invoice: Replacement Invoice Pictures:Pictures . Fire Report: Fire Report Repair Invoice:Repair Invoice Inaccurate or incomplete report will slow the claim process.