File A Home Insurance Claim Insured Name* First Last Mobile Phone*Is It Ok For The Carrier To Text Regarding Your Claim?YesNoEmail Insurance CarrierErie InsuranceNationwide InsuranceState AutoForemostUPC InsuranceUniversal Property & CasualtyOtherPolicy Number What Best Describes The Cause Of The Incident* My Property Was Damaged By Fire Or Water My Property Was Damaged By An Act Of Nature My Property Was Lost Or Was Stolen In A Criminal Act My Property Was Damaged By Another Cause Someone Is Making A Claim Against Me (Liability Loss) Something Else Happened What Caused The Damage Fire Or Smoke Water From Sewer Or Drain Backup Rupturing And/Or Leaking Of Plumbing Pipes Other Water Damage Or Mold What Caused The Damage Wind Hail Weight Of Ice or Snow Lightning or Power Surge Tree Debris Ground Movement What Caused The Damage Theft Vandalism Identity Theft What Caused The Damage Food Spoilage Vehicle Mechanical Or Electrical Breakdown Explosion Collapse Pollution, Bio-Hazard, or Toxic Materials Falling Objects What Caused The Damage Injury To Others Or Damage To Their Property Injury Caused By An Animal Personal & Advertising Liability (Slander / Libel) Professional Liability Liquor Liability Assault Or Battery Approximate Date Of Loss MM slash DD slash YYYY Approximate Time Of Loss : Hours Minutes AM PM AM/PM Where Did The Incident Occur? Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Damage Details (Enter At Least One) Home | Dwelling Other Structures Personal Property Someone Else's Property Someone Else (Personal Injury) Where Did The Damage Occur? (Select All That Apply) Exterior Interior What Exterior Damage Occurred? Roof Windows Doors Exterior Walls Gutters AC | Furnace Other How Many Stories Are In The Home | Dwelling? 1 2 3+ What Interior Damage Occurred? Ceiling Floors Walls Other How Many Rooms Are Affected? 1 2 3 4+ Is The Home | Building Safe To Live In? Yes No What Other Structures Were Damaged? Detached Garage Shed Fence Pool Other Please Provide Details About What Was DamagedPlease Provide Details About What Was DamagedDetails (Please Give Details As To What Happened)Upload Any Files Drop files here or Select files Max. file size: 60 MB. Δ Learn More: Will Homeowners Insurance Cover Tree Damage
