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Lender Placed Hazard or Flood Claims

* indicates required field

Loan Number

Name of Lender / Institution

Client Number

Property Address

Is the property occupied or vacant?
 Occupied Vacant

If vacant, when did it become vacant?

Date Of Loss

How was damage / loss discovered?

Loss type

Description of loss / damage


Reporting Party

Name *

Phone Number *

Email Address *


Contact Person

Name *

Home Phone Number *

Work Phone Number

Email Address *

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For your protection California law requires the following to appear on this form: “Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.”