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Property/Injury Claim Form

  1. First Name and Last Name

  2. Include area code

  3. 0 of 10000 max characters

    (State in detail where, when, and how the accident occurred and the extent of any injuries or damages)

  4. If no witnesses, enter “NONE” in the box above.

  5. Signature of Claimant*

    By checking the "I agree" box below, you agree and acknowledge that

    1. Your application will not be signed in the sense of a traditional paper document.
    2. By signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature.
    3. You may still be required to provide a traditional signature at a later date.
  6.  (Please enter your First Name and Last Name)

  7. Signature of Witness*

    By checking the "I agree" box below, you agree and acknowledge that

    1. Your application will not be signed in the sense of a traditional paper document.
    2. By signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature.
    3. You may still be required to provide a traditional signature at a later date.
  8. (Please enter your First Name and Last Name)

    Please note: If no witnesses, enter “NONE” in the box above.

  9. Signature of Additional Witness

    By checking the "I agree" box below, you agree and acknowledge that

    1. Your application will not be signed in the sense of a traditional paper document.
    2. By signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature.
    3. You may still be required to provide a traditional signature at a later date.
  10. (Please enter your First Name and Last Name)

    Please note: If no witnesses, enter “NONE” in the box above.

  11. Leave This Blank:

  12. This field is not part of the form submission.