Claim Application

Non Weather Related Claim Application

Required fields are marked with *

What type of property is this application for? *

Residential

Commercial

Identification

First Name*

Last Name*

Phone Type*

Phone Number (include area code)*

Alt Phone Type

Alternate Phone Number (include area code)

Email Address*

LCEC Account Number

Mailing Address

My address is outside the US? *

Yes

Mailing Address*

Mailing Address 2

Mailing City*

Mailing State*

Mailing Zip*

Mailing Address and incident address are the same? *

Yes

Incident Details

Incident Date*

Incident Address*

Incident Address 2

Incident City*

Incident Zip*

Description of Damage

Incident was filed with insurance?*

Yes

Loss Calculator - Property Items

Item Type

Item Description

Cost

Loss Calculator - Food Items

Item Description

Cost Amount

Sub Total of all the items above (Property and Food items) = $0

Upload Additional Document (if necessary), accepted file types are: pdf, docx, jpg, jpeg, gif

Upload Additional Doc

Signature:*

800-599-2356