Capacity Insurance – claim

To Submit a Claim, please fill out the information below. All fields marked with an asterisk(*) are required to complete the request.
Who should we contact about this claim?
*Contact Person
  *First Name *Last Name
What phone number can you be reached at? *Provide at least one.
Home Phone --  
Business Phone -- ext
Mobile Phone --  
What is your Email Address?
*Email Address
Please fill out the following information regarding the claim:
*Policy Number
*Policy Holder
  *First Name *Last Name
What is the address of the covered location?
*Address
 
*City
State
*Zip
Please tell us the details of the claim:
*Type of Loss?
*Date/Time of Loss?
Time
 
DD/MM/YYYY   00:00 am/pm
Where did it occur?
e.g. home, business, other..
Was the loss because of a Hurricane?
Was it a Hurricane? If yes, enter the name.
Which Hurricane?
Is the property still Inhabitable?
Still Inhabitable?
Please describe what happened below:
*Description of Loss
400 Characters Max
Characters Left = 400
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