Claim for Community Association Property Damage; Personal Liability, & Directors & Officers Liability

If you have been notified or are aware of a Claim for being made against Board or Association by a third party, please complete this form.

Name of Person Reporting Incident (Property Management Company or Self Managed Board Member): *

Address: *

City: *

State: *

Zip Code: *

Direct Phone Number: *

Email address: *

Association: *

Owner Name: *

Owner Phone: *

Email address: *

Tenant's Name or N/A:

Tenant's Phone:

Unit Number: *

Owner's Insurance Company *

Adjuster: *

Phone Number: *

Email Address: *

Claim Number: *

Report of Incident

Date of Claim: *

Approximate Time of Claim:

Incident Reported By:

Email Address:

Description of the Incident

If you have a completed Incident Form, please attach or request a form for Owner's completion.

Be as detailed as possible listing, who, when, and what happened, then complete the appropriate section(s) below (Personal Injury and/or Property). If this is a third-party claim, please provide copies of any correspondence received. If there is a law suit, please attache at your earliest convenience.

Description of the Claim: *

Upload any correspondence you have received to date.

Was this a weather-related claim? *

Yes

If yes, please explain: *

Has any action been taken by the management company other than reporting to us? *

Yes

If yes, please explain: *

Have you sent a maintenance person to checkout reported issue? Please include their report. *

Yes

Maintenance Report

Personal Injury Claims

Type of Claim: *

Injury (Guest)

Injury (Owner)

Injury (None)

Name of Injured Party: *

Current Condition of Injured Party: *

Address: *

City: *

State: *

Zip Code: *

Email Address *

Phone Number: *

Was a Child Injured? *

Yes

If yes, witness name and contact information: *

Was there a witness? *

Yes

If yes, witness name and contact information: *

Property Claim

Is the current conditions the unit livable? *

Yes

If no, please explain: *

Has a fire or water restoration company been contacted by owner's HO-6 carrier? *

Yes

Name of Company: *

Contact Email: *

Contact Name: *

Contact Phone: *

Do you wish to only report this for record purposes only? *

Yes

Please do NOT report claim

Please report claim immediately

Auto	Burglary	Fire
Flood	Hail	Windstorm
Vandalism	Sewer Back Up Damage	N/A