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Clothing Claims Form
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Claim Number:Coverage Limits:
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Name:Please fill in this fieldBuilding: $ -
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Address:Please fill in this fieldBPP: $ -
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Phone number

Email address		Please fill in this fieldDeductible: $ -
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Date of Drop off :Please fill in this field
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Ticket/Invoice Number:Please fill in this field
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* PLEASE SUBMIT THE RECEIPTS and PROOF OF PURCHASE
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TO BE COMPLETED BY INSUREDTO BE COMPLETED BY ADJUSTER
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#DescriptionAge(in yrs)QuantityUnit PriceTotalRCVDepreciation (% by Year)Depreciation Amount ($)ACV
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FOR YOUR PROTECTION, CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO
KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN A STATE PRISON		SETTLEMENT BREAKDOWN
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RCV $ -
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Less Depreciation $ -
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ACV $ -
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Less Deductible
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TOTAL $ -
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Completion of this form neither confirms nor denies coverage for all items listed.
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SignatureDate
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