Claim Form

To report a claim to AIUA, please complete this form

AIUA Policy Number

Date of Loss

Date Reported

Insured Name

Mailing Address

City

State

Zip

Home Phone

Cell Phone

I would like to sign up to receive text messages about my claim and/or policy on the cell phone number listed above.

Other Phone

Insured Property Address

Your name (if different from named insured)

Your email address (if different from named insured)

Your phone number (if different from named insured)

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 have read and understand the above statement.