Property Loss

Date Of Loss(Required)

School District(Required)

Primary Phone #(Required)

Secondary Phone #(Required)

Primary Email Address(Required)

Secondary Email Address

Name Of Contact(Required)

First Middle Last

Primary Phone #(Required)

Secondary Phone #(Required)

Email Address(Required)

Secondary Email Address

Location Of Loss(Required)

Street Address or P.O Box City State Zip

Please list approximate address

Description location of loss if not a specific street address(Required)

Kind of Loss(Required)

Fire

Theft

Lightning

Hail

Flood

Wind

Description of Loss & Damage(Required)

(ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

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