Dc Water Property Damage Claim Form printable pdf download

DC WATER PROPERTY DAMAGE CLAIM FORM

Fully complete this form and send it to the District of Columbia Water and Sewer Authority, Office of Risk

Management, 5000 Overlook Avenue SW, Washington, DC 20032. All claims are independently investigated.

Submitting this form initiates a review of your claim. Submitting this form does not establish liability, and DC Water

does not waive any defenses.

________________________________________________________________________________________

Name

Daytime Phone Number

________________________________________________________________________________________

Address

Evening Phone Number

________________________________________________________________________________________

House or Apt. No.

Street

________________________________________________________________________________________

City

State

Zip

CAUSE OF DAMAGE □ Sewer Back Up □ Water Damage

□ Other __________________________

Date of Loss: ______________ Time: ____________

AM/PM

Date Reported to DC Water:________

Homeowner’s insurance carrier name, address & policy #: ___________________________________________

Incident Description: _________________________________________________________________________

__________________________________________________________________________________________

Please itemize all personal belongings below included in your claim. Note that any valid claim will be paid on an

actual cash value basis, which means replacement cost less depreciation. Should your property require repair,

submit a minimum of two estimates for the repair work, along with this claim form. Also note that it is the

responsibility of the person filing the claim to obtain estimates and contracts for repair work. If repairs have been

completed, please submit the contract and paid invoice for services provided. DC Water is not responsible for the

quality of the work performed by the contractors you select. Filing of this form does not guarantee acceptance or

payment for damages.

DAMAGED ITEM(S)

DATE OF

LOCATION OF

COST AT TIME

(Include a full description, including extent of damages)

PURCHASE

OF PURCHASE

*Attach additional pages as needed

I hereby certify that the information stated is true to the best of my knowledge

__________________________________

_______________________________________

Signature of Claimant

Date

Warning: It is a crime to provide false or misleading information to DC Water. Any claim against the Authority, knowing such

claim to be false, fictitious or fraudulent is subject to fine or imprisonment

Dc Water Property Damage Claim Form

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