Paul & Dixon Insurance Agency - Report a Homeowner's Claim

PRELIMINARY REPORT OF HOMEOWNERS CLAIM

Name of Insured

First

Last

Address of Insured

Address

City

State

Zip Code

Preferred Phone

Alternate Phone

Email Address

Claim Information

Policy Number (if available)

Date of Accident/Loss

Location of Accident/Loss

Cause of Loss

Describe if Other Cause

Emergency Services Required

Police or Fire Dept. Notified?

Yes

No

Temporary shelter required?

Yes

No

Windows require board up?

Yes

No

Person(s) Injured

Name of Injured #1

Phone of Injured #1

Describe Injuries (if any)

Cause of Injuries (if any)

Name of Injured #2

Phone of Injured #2

Describe Injuries (if any)

Cause of Injuries (if any)

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