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Spokane

Student Property Claim Form

Student Information (*required fields)
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 reach you by phone at the above number between 8:00AM and 4:00 PM.
Home Information
Important in case we need to contact you during vacation.
Home Address
Home Phone Number

Loss Information
Date and time of loss

Location of Loss (specific)

Estimated Total Value of Property Lost
(to be itemized further down on form)
Detailed description of how loss occurred
Important Information
Deductible
Loss other than theft No deductible
Losses by theft of Stereo, TV, bicycles and computers $100 per loss
Losses by theft of all other property $50 per loss
Special Limits
1. $100 with respect to theft of jewelry 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 / Received Where Purchase (if known) Estimated New Cost
Other Comments
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

*Note: You must retain a printed copy of this form as verification that it was submitted. If you are unable to print this form then you must call our office to verify receipt. Call 1-800-223-7954 and request Student Services.



Claims to be adjusted by:
North Pacific Insurance Claims Office
501 N Riverpoint Blvd. Suite 104
Spokane, WA 99202
(509) 455-7514 ext. 3