Student Property Claim Form

Student Information Name of Student *
Name of Univ./College *
Campus Address *
Campus Phone Number *
Email Address *
Order Confirmation Number
Please indicate the best time for the Claims Adjuster to read you by phone at the above number between 8:00AM and 4:00 PM.

Home information

Important incase we need to contact you during vacation.

Home Address
Home Phone

Loss Information Date and time of loss
Location of Loss (specific)
Estimated Total Value of Property Lost
Detailed description of how loss occured

Important Information

Deductible
Loss other than theft	No deductable
Losses by theft of Stereo, TV, bicycles and computers	$100 per loss
Losses by theft of all property	$50 per loss
Special Limits
1. $100 with respect to theft of jewlery and furs
2. $500 with respects to theft of stereos, television and DVD equipment and bicycles

Detailed Description of Property Damage or Stolen

Please include make, model number and serial number, if available. Attach receipt(s) of purchase if possible. The more complete the description, the more promptly the claim may be settled.

Item	Approx. Date Purchased / Recieved	Where Purchased (if known)	Estimated New Cost

Other Comments

Human Verification

If this is a theft loss you are required to report it to the Campus or City Police within 24 hours following discovery of the loss, and in addition, date the following release.

Please check this box to authorize the University/City Police Department to reveal all pertinent information concerning my Police Case Report # .

Date:

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Student Property Claim Form

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