Property Claim Form
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11850 Mt. Diablo Blvd., Suite 400
Walnut Creek, CA 94596
CA License #0H66758
P 925.482.1000 F 925.482.1001
24-Hour Claims 925.322.9882
claims@legacyrisk.net
Property Claim Form
Contact: _________________________________________
Phone No.: ______________________________
Property Name: ___________________________________________ Property Phone No.: ______________________________
Property Address: ______________________________________
Property Manager: __________________________________
Date of Loss: __________
Time of Loss: ___________
Location of Loss: ___________________________
Unit #: _______
Fire
Water Damage
Theft
Other (explain) _________________________________________
Type of Loss:
_________________________________________________________________________________________________________
COMPLETE DESCRIPTION OF LOSS:
Description of Occurrence. ___________________________________________________________________________________
_________________________________________________________________________________________________________
Describe Physical Damage to Property, or Provide List of Stolen Property: _____________________________________________
_________________________________________________________________________________________________________
Weather Conditions: ________________________________________________________________________________________
Physical Condition before incident (clean, dry, wet, well lit, ventilated) _________________________________________________
_________________________________________________________________________________________________________
Police Contacted: Yes No Name of Officer: ____________________ Phone No. __________________ Case No.: _______
Fire Dept. Contacted: Yes No Name of Officer: __________________ Phone No. __________________ Case No.:_______
WITNESS INFORMATION
Business Home Cell
Name: _________________________________
Phone No.: ___________________________
Address: _________________________________________________________________________________________________
Witness Statement: _________________________________________________________________________________________
Business Home Cell
Name: _________________________________
Phone No.: ___________________________
Address: _________________________________________________________________________________________________
Witness Statement: _________________________________________________________________________________________
POST INCIDENT INSPECTION
Casual Analysis: ___________________________________________________________________________________________
Recommendation to Prevent Reoccurrence: _____________________________________________________________________
_________________________________________________________________________________________________________
Questions, Matter of Concern, Issues to be addressed: ____________________________________________________________
_________________________________________________________________________________________________________
Please include any photos of the scene. There will be an option to attach them once you click Submit. You will be prompted to
choose Desktop Email Application or Internet Email. If you choose Desktop Email Application a new email will appear with
your completed form attached. This will allow you to also include any photos you may have. If you choose Internet Email you will
Submit
be prompted to save the completed PDF to your computer. You can then email the form and any photos to claims@legacyrisk.net.
Reported By
__________________________________
Signature
_________________________________
Title
__________________________________
Date
_________________________________
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