Vacant Property Insurance Claim
Policyholder Information
Name
Policy Number
Contact Number
Email Address
Mailing Address
Property Details
Property Address
Property Type
Period Vacant (dates)
Incident Details
Date of Incident
Time of Incident
Description of Incident
Is a police/fire report filed?
Police/Fire Report Number
Damages and Losses
Description of Damages/Losses
Estimated Cost of Damages
Photos/Documentation Attached
Declaration
Signature
Date