Flood Insurance Proof of Loss Form
Policyholder Information
Insured Name
Policy Number
Mailing Address
Phone Number
Property Information
Loss Location Address
Date of Loss
Description of Damaged Property
Claim Details
Estimate of Damages (Amount)
Cause of Loss
Brief Description of Flood Event
Additional Information
Mortgagee Name
Mortgage Account Number
Other Insurance (if any)
Policyholder Signature
Date