Cornerstone

Home Insurance Claim

Type of Claim *

Policyholder Type *

Policy Number *

Phone No *

Email Address *

Address *

City *

State *

Date of Incident (yyyy-mm-dd) *

Time of Incident *

Where Did the Incident Occur? *

Brief Details of Incident *

Brief Description of Property/Content Damaged or Stolen *

Value of Property/Content Damaged or Stolen *

Upload Picture 1 *

Upload Picture 2 *

Upload Picture 3 *

Estimate of Repairs(If Building)

Statement of claim (Sheet showing quantities and value of Property/Stock damaged/Stolen) *

Purchase Receipt/Invoice of stolen items(If Theft/Burglary)

Estimate Of Claim *

Witness 1 Name and Telephone Number (Name/Tel etc) *

Witness 2 Name and Telephone Number (Name/Tel etc) *

Statement of Authenticity/Truth of Details Given Above (Please Tick Box). *