File a Claim

FILE A CLAIM

1Basic Information

2Tenancy Details

3Loss of Rent

4Property Damage

5Documentation

Before completing this form, please note:

Claims for Malicious Damage and/or Theft each have a $1,500 deductible applicable to the claim.
It is unlawful to knowingly provide false, incomplete or misleading facts, information, or statements to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and/or civil damages.

Property Management Company/Agency(Required)

Property Manager Submitting the Claim(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Property where loss or damage occurred

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Landlord's Name(Required)

First Last

Policy Number(Required)

Full name of delinquent tenant(Required)

First Middle Last

Forwarding details for the defaulting tenant

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone

Cell Phone

Lease type(Required)

Fixed term

Month to month

Lease Term Start Date(Required)

MM slash DD slash YYYY

Lease Term End Date(Required)

MM slash DD slash YYYY

Please provide any other information/contact details for the tenants mentioned on the lease

Please complete the fields below if you are claiming loss of rent. Otherwise, continue to the next page.

Type of Loss

Tenant Skip (lease break)

Tenant Delinquency (Writ of Possession Obtained)

Tenant Delinquency (Eviction Order Granted)

Tenant Death (Sole Tenancy)

Tenant Murder or Suicide

Untenable (Condo’s; fire, explosion or water damage)

Untenable (due to malicious damage to the building)

Untenable (due to malicious damage to the contents)

Victims of Violence

Prevention of access/denial of access

Other

Please specify other type(s) of loss(Required)

Date tenant moved into the property

MM slash DD slash YYYY

Date tenant moved out of the property

MM slash DD slash YYYY

Did the tenant give any notice to leave the property?

Yes

When did the tenant give notice?

MM slash DD slash YYYY

How much notice was the tenant required to give to leave the property?

Was an eviction order granted?

Yes

Writ of Possession?

Yes

Date rent paid up to

(excluding security deposit)

MM slash DD slash YYYY

Monthly Rent

Security Deposit Held

Has the property been re-leased?

Yes

What date was it re-leased?

MM slash DD slash YYYY

What actions have been taken to minimize loss and return the property to market since becoming aware of the delinquency or loss?

Property Damage or other insured event

Date damage was found

MM slash DD slash YYYY

Did the abovenamed tenant cause this damage?

Yes

Unknown

Please provide the information for the person who caused the damage:

Who caused this damage?

First Last

Phone

Type of damage/event being claimed

Contents for Condos

Fire or explosion

Water damage

Malicious Damage/Theft

Malicious damage to building

Theft or damage due to theft to building

Malicious damage to contents

Theft or damage due to theft to contents

Has the damage been reported to the police?

Yes

Additional loss being claimed

Eviction filing fee, Eviction defense costs

Sheriff, Marshall or Constable fees

Loss due to use of Digital lock boxes

Service and/or companion animal damage

Re-keying of locks

Claim Preparation and Submission fee ($100)

Other

What is your additional loss?

Please provide a FULL description of what has happened

Please provide details of Security Deposit expenses and loss or damage being claimed either by listing below or attaching a deposit disposition report from your software.

Security Deposit

Item

Invoice Amount

Copies of itemized quotes/invoices for security deposit items listed above

Drop files here or

Max. file size: 50 MB, Max. files: 5.

Theft or Damage

Item

Invoice Amount

Copies of itemized quotes/invoices for theft or damage items listed above

Drop files here or

Max. file size: 50 MB, Max. files: 5.

Documents Required

To help with the fast and efficient processing of your claim, please provide as much information concerning the claim as you can, complete all questions on this form and attach copies of the following documents. If you cannot provide certain documents, please attach a written explanation as to why.

A copy of the delinquent tenant’s lease agreement(Required)

I have this document

I cannot provide this document

Please upload the above document

Drop files here or

Max. file size: 50 MB, Max. files: 5.

A copy of the tenant’s rental payment history if the claim involves loss of rent, malicious damage or theft by the tenant(Required)

I have this document

I cannot provide this document

Please upload the above document

Drop files here or

Max. file size: 50 MB, Max. files: 5.

Why can you not provide the above document?(Required)

Copies of any written notices, eviction orders and possession proceedings documents(Required)

I have this document

I cannot provide this document

Please upload the above document

Drop files here or

Max. file size: 50 MB, Max. files: 5.

Why can you not provide the above document?(Required)

Evidence of dated, published advertising to demonstrate efforts to re-lease the property, or copy of online advertisement if sole advertising medium(Required)

I have this document

I cannot provide this document

Please upload the above document

Drop files here or

Max. file size: 50 MB, Max. files: 5.

Why can you not provide the above document?(Required)

A copy of the new tenants lease agreement(Required)

I have this document

I cannot provide this document

Please upload the above document

Max. file size: 50 MB.

Why can you not provide the above document?(Required)

Copies of move-in/move-out and any other property inspection reports(Required)

I have this document

I cannot provide this document

Document is not applicable

Please upload the above document

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Why can you not provide the above document?(Required)

Labelled color photos or video evidence to support a claim for damages(Required)

I have this document

I cannot provide this document

Document is not applicable

Please upload the above document

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Why can you not provide the above document?(Required)

Proof of ownership i.e. receipts, valuations, photographs, warranties, instruction manuals etc. for items which have been stolen or damaged(Required)

I have this document

I cannot provide this document

Document is not applicable

Please upload the above document

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Why can you not provide the above document?(Required)

Two itemized quotes to repair/replace damaged items(Required)

I have this document

I cannot provide this document

Document is not applicable

Please upload the above document

Drop files here or

Max. file size: 50 MB, Max. files: 2.

Why can you not provide the above document?(Required)

A copy of the outgoing tenants application form and forwarding address (if obtained)(Required)

I have this document

I cannot provide this document

Please upload the above document

Drop files here or

Max. file size: 50 MB, Max. files: 2.

Why can you not provide the above document?(Required)

Invoices to justify the cost of leasing expenses that were deducted from the tenant’s security deposit(Required)

I have this document

I cannot provide this document

Document is not applicable

Please upload the above document

Drop files here or

Max. file size: 50 MB, Max. files: 2.

Why can you not provide the above document?(Required)

Documentation of verifiable service animal(Required)

I have this document

I cannot provide this document

Documentation is not applicable

Please upload the above document

Drop files here or

Max. file size: 50 MB, Max. files: 2.

Why can you not provide the above document?(Required)

Any other court issued documents, letters, claims, writ or summons, in relation to a claim(Required)

I have these documents

I do not have any other documents to provide

Please upload the above document(s)

Drop files here or

Max. file size: 50 MB, Max. files: 2.

A copy of the police report for malicious damage, theft or arson (if obtained)(Required)

I have these documents

I cannot provide these documents

There was no police report

Please upload the above document(s)

Drop files here or

Max. file size: 50 MB, Max. files: 2.

Why can you not provide the above document?(Required)

This field is hidden when viewing the form

$100 claim preparation fee

Property Manager needs to provide an invoice for this payable to the Property Manager

I have these documents

I cannot provide these documents

This field is hidden when viewing the form

Please upload the above document(s)

Drop files here or

Max. file size: 50 MB, Max. files: 2.

This field is hidden when viewing the form

Why can you not provide the above document?

Payment

Payment of the assessed claim amount will be sent by check payable to the Property Management Company under which this property is insured within our policy system.

Declaration

By submitting this form, I declare the statement and particulars provided to be true and correct.

By submitting this form, I declare the statement and particulars provided to be true and correct.(Required)

I agree

I disagree

Name(Required)

First Last

Today's Date(Required)

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.