Peck-Glasgow Agency, Inc.
Please fill out this form as completely as possible.
Homeowners Insurance
Report a Claim
Policy Number:
Your Name:
Contact Person:
Whom should the adjuster call to settle your claim?
Name:
Home Phone:
Work Phone:
e-Mail:
Best time to call:
Authority Contacted:
Police/Fire dept:
Report number:
Claim Information:
Date of loss:
Location of claim:
Cause of loss:
Fire
Hail
Lightning
Smoke
Theft
Vandalism
Vehicle
Water
Wind
Other--describe below
Describe Your Damages/Loss:
Emergency services needed:
Temporary Shelter Required?
Yes
No
Windows Required Boardup?
Yes
No
Other?:
Persons Injured:
Name/address
Phone number:
Nature of injuries:
Cause of injuries:
Comments and/or Other Information:
Please Note:
Insurance coverage cannot be bound without a written binder from our office.