Liability Damage Waiver: Submit Claim

Name
This field is for validation purposes and should be left unchanged.
Account Number*
Name on Account*
Requesting Party (if not customer)
Main Phone*
Alternate Phone
Email*
Address of Building Location*
Street Address Address Line 2 City State ZIP Code
Is your Mailing address different than the address of the building?*
- Yes
- No
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Date of Incident
MM slash DD slash YYYY
Is the building a total loss?
- Yes
- No
Details of incident*
Fire/Theft reports
In case of a fire - You must attach a fire report.
In case of a theft - You must attach a police report.
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 16 MB, Max. files: 2.
ALL PAYMENTS MUST BE CURRENT AT THE TIME OF INCIDENT
ALL CLAIMS MUST BE SUBMITTED WITH PROPER PAPERWORK WITHIN 30 DAYS OF DAMAGE OR LOSS
By submitting this request, I acknowledge that all information submitted herein is accurate. I understand that my account must be current (all payments, late fees and LDW fees) at the time of incident. If my account is not current, I understand that I will be responsible for all repairs needed. If the building is a total loss, I understand that I will be responsible for the Fair Market Value of the building. LDW does not cover damage caused by water, moisture, scratches, mysterious disappearance, vandalism, abandonment, or any other intentional damage by renter. Theft must be reported to the police and the police report must be provided at the time the claim is made. Damage caused by fire must be reported and an official report must be provided at the time the claim is made.
CAPTCHA

ALL PAYMENTS MUST BE CURRENT AT THE TIME OF INCIDENT

ALL CLAIMS MUST BE SUBMITTED WITH PROPER PAPERWORK WITHIN 30 DAYS OF DAMAGE OR LOSS