"On behalf of all the residents affected by the San Bruno/Glenview fire and the Department of Insurance staff, I would like to personally thank you for your participation in the San Bruno Insurance Recovery Forum...the forum provided fire survivors in the community the opportunity to ask questions, receive information, and express their concerns..."
The following are samples of claim and proof of loss forms. You can use them for "dwelling" and "contents" claims. Please refer to our Dwelling Tips, Claim Tips, the Disaster Recovery Handbook, and other United Policyholders' publications for guidance on documenting loss and damage fully and getting fairly, promptly paid on claims.
- Sample Letter Requesting Copy of Policy
- Sample Letter Requesting Information About Insurance Benefits for Temporary Living Expenses ("ALE/Loss of Use")
- Sample Letter Asking for the Waiver of the Contents Itemization Requirement
- Sample Letter Asking for a Personal Property Claim Settlement
- Sample Letter Requesting Payment History
- Sample Letter Protecting Your Legal Rights
- Sample Letter Requesting Extensions of Policy Deadlines
- Sample Letter Requesting Information About Claim Denial
Example Claim Documents
Dwelling repairs/rebuilding/scope of loss:
- Debris Removal
- Dwelling Scope of Loss
- Code Upgrades
- Other Stuctures
- Rebuilding Estimate
- Trade Summary Breakdown
- General Earthquake Damage Inspection Checklist
Inventory/Personal Property Claim Worksheets (Excel doc) - United Policyholders Home Inventory Worksheets for you to complete and save on your computer or recovery flash drive
Example of a completed home inventory - 2003 Cedar Fire Survivor and Disaster Recovery Mentor, Julie Robinson, has donated her contents claim form to United Policyholders
- Depreciation Guide by "Claims Pages" - an insurance industry resource website. Look under "Tools" at www.claimspages.com to find this and other tools for calculating losses and costs to replace/repair.
- Example of Insurance Company Depreciation Guide
Sample Damage Reports and Documentation
- Smoke Containimation and Damage Report
- Air Quality/Industrial Hygienist Report
- Asbestos, Lead and Mold Inspection Report
- Thermal Damage to Window (Manufacturer's Opinion)
- Thermal Damage to Window (Insurer's Hired Expert)
Other types of damage and useful reports may include: cement and asphalt, decks, engineering, fire cause and origin, gutters, insulation, roofs, siding and stucco, and seismic/earthquake.
Please send an email to firstname.lastname@example.org if you are looking for a type of report you do not see here or would like to contribute a sample report to UP. All samples are redacted for personal information.