General-Loss-Questionnaire

Address

Please Describe Circumstances of Loss in Detail:
Prior Claims/Dates:
Is this Your Primary Residence?
Rental Property?
Property Status
Date Last Occupied
If Unoccupied.
What is the Date of Loss?
When did you become aware of the Loss?
What was the Cause of this Loss?
Recent Repairs or Alterations:
PLEASE SEND ANY ADDITIONAL INFORMATION THAT PERTAINS TO YOUR CLAIM TO OUR OFFICE AS SOON AS POSSIBLE.
Full Name
First Name Last Name
Please Initial Here
I have Filled out this Claim Form to the best of my Knowledge.
Date
/ Month / Day Year
In making this adjustment, all the conditions specified in the policy are expressly reserved and the rights of the insurance company are not to be deemed waived in any way.
J.L PAYAN & ASSOCIATES, INC.

PO BOX 152 Sterling IL 61081

815-441-9151 property@payanadjusting.com
Should be Empty:

PO Box 152 Sterling, IL 61081

email: property@payanadjusting.com

call: (815) 441-9151

fax: (888) 696-4495

INSURED'S LOSS QUESTIONNAIRE