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AIUA Policy Number
Date of Loss
Date Reported
* Hurricane Sally made landfall on 9/16/20
Insured Name
Mailing Address
City
State
Zip
Home Phone
Cell/Work Phone
Other Phone
Email
Insured Property Address
Name of Person Reporting this Claim
Email Address of Person Reporting this Claim
Phone # of Person Reporting this Claim
Kind of Loss
Fire
Lightning
Wind
Hail
Vandalism
Flood
Other
Severity of Loss
1 - Minor
2 - Significant
3 - Major
4 - Severe
5 - Total Loss
Detailed Description
Estimated Amount of Entire Loss
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
I Acknowledge