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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
Email
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)
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 have read and understand the above statement.