Homeowners Claim Report Changes and reports are NOT effective until we are able to confirm them with you directly in person or over the phone.   Who Are You? First Name   Last Name   Email Address   Home Phone   Work Phone Date - - - - - - - - - January February March April May June July August September October November December / - - 01 02 03 04 05 06 07 08 09 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Address of Insured Property Address   City   State   Zip Code Information About the Incident Date & Time of Incident   Where did the Accident Occur?   What Authorities were Contacted?   What is your estimate of the value of the damage or incident?   Type of Damage - - - - - - - - - - - - - - Fire Theft Weather Related Other Describe the Damage or Incident   Changes and reports are NOT effective until we are able to confirm them with you directly in person or over the phone.