Earthquake

Hurricane Beryl Claim Form

If you have suffered damages as a result of Hurricane Beryl, please notify us of your claim by completing and submitting the form below

Date of Loss:*
MM slash DD slash YYYY
Policy Number(s).: (Please list all applicable policy #s)*

(Please list all applicable policy #s)
Is the property covered by any other insurance?*
If yes, please provide the name of the insurer*
THE INSURED
Insured(s) Name:*
Physical Address:*
Contact Information: (Phone)*
(Email)*
THE EVENT/LOSS TYPE
Complete the applicable section(s) below to describe the loss you have incurred from a Hurricane Beryl:
Property
Roof*
Wall*
Windows*
Floor*
Flooding*
Location Of loss*
Motor
Windshield*
Body*
Flooding*
Location Of loss
Marine
Mast*
Hull*
Sinking*
Total Loss*
Location Of loss
Have actions been taken to mitigate or lessen the damages?*
If yes provide details for each asset type that you have completed above:
We would like to send an adjuster to assess your loss. Please provide us with directions to the relevant loss location(s):
Provide any additional details of the loss:
PLEASE ATTACH ANY PHOTOS AND LOSS ESTIMATE DOCUMENTS YOU MAY HAVE IN YOUR POSSESSION TO SUPPORT YOUR CLAIM(S)
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 80 MB, Max. files: 5.
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 80 MB, Max. files: 5.
You can select multiple documents by dropping them here or by holding the CTRL button when selecting
VERY IMPORTANT - FRAUDULENT AND EXAGGERATED CLAIMS

The above answers to our questions will be the basis of consideration of your claim. You must ensure that all information is true and correct to the best of your knowledge and belief, and that all material facts have been disclosed. A material fact is one that is likely to influence us in the assessment or acceptance of this claim, or one that is likely to influence our consideration of cover under the terms of your policy. If you are in any doubt as to whether a fact is material, you must disclose it.
FAILURE TO DO THIS MAY MEAN THAT YOUR POLICY BECOMES INVALID AND A CLAIM PAYMENT WILL NOT BE MADE.
DECLARATION
DECLARATION*
- I/We declare the foregoing particulars to be correct according to my information and belief. I/We understand that you may seek information from other insurers to check the answers I/we have provided.
PLEASE ATTACH A COPY OF A VALID GOVERNMENT ISSUED PHOTO IDENTIFICATION DOCUMENT
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Earthquake

Hurricane Beryl Claim Form

THE INSURED

THE EVENT/LOSS TYPE

PLEASE ATTACH ANY PHOTOS AND LOSS ESTIMATE DOCUMENTS YOU MAY HAVE IN YOUR POSSESSION TO SUPPORT YOUR CLAIM(S)

VERY IMPORTANT - FRAUDULENT AND EXAGGERATED CLAIMS

DECLARATION

PLEASE ATTACH A COPY OF A VALID GOVERNMENT ISSUED PHOTO IDENTIFICATION DOCUMENT

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