Web Reported Claim

Begin The Claim

What is your relationship to the claim?

Policyholder Other

Policy #

Your First Name*

Your Last Name*

Your Address*

Your City*

Your State*

Your Zip*

Your Phone

Your Email* (A copy of this Web Reported Claim will be sent to the below e-mail address.)

Date of Loss*

Type of Default*

Address Where Default Occurred

Location#

Address*

Building#

Unit#

City*

County*

State*

Zip*

Monthly Rental Income for This Unit

Number of Months Rent in Arrears

Amount of Legal Expenses Incurred (if any)

Policyholder

Check if same as person reporting the claim

Yes No

Company Name (if applicable)*

First Name*

Last Name*

Address

City

State

Zip

Phone

Preferred Contact

Summary

Your claim is now ready to submit.

Any other information to support your claim.

**Attachments

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** You may upload the following information to facilitate the claim process:

A copy of the lease for the rental unit in force at the time of the rent default.
Evidence of the pre-lease screening checks on the tenant of the rental unit substantiating that the tenant met the screening criteria outlined in the policy.
Copies of notices sent to the tenant of the rental unit regarding rent payments.
Copies of any legal documents relating to eviction proceedings.
Receipts or invoices to substantiate any legal expenses.