Contents Inventory Form

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					                                                                          Contents Inventory Form

Insured _____________________________                                                                                                                   Claim Number ______________________________
                                                                                                                                                               umber________________________________________


Date of Loss _________________________                                                                                                                  Claim Rep _________________________________

Room ______________________________


                                                      TO BE COMPLETED BY INSURED                                                                        TO BE COMPLETED BY CLAIM REPRESENTATIVE
          1          2                            3                 4            5                     6                   7                        8         9                 10                            11                12                      13

                                               Brand Name and             Purchased or                Date of Purchase Replacement, Repair                                            Adjustments to R/C **
Item No       Quantity Description of Property Model Number               Obtained From Documentation & Purchase Price or Restoration Cost % Tax                 R/C or Repair Cost   (depreciation)               Settlement        Maximum R/C Benefits




A-Appraisal              B-Paid Bill or receipt       C-Canceled Check                                     TOTALS

E-Estimate               P=Photo                      CR-Credit Card Receipt                                                                                                          DEDUCTIBLE

O-Other                                                                                                                                                                               SETTLEMENT

Home and Work Phone No.: (_____) ____________ / _____________
The above information is true to the best of my knowledge.
                                                                                                                                                                                      ** Depreciated Amount
                                                         D
Insured's Signature ______________________________________ ate _____________


NOTE: For your protection, the law of your state requires the following to appear on this form.
Any person who knowingly and with intent to injure,defraud or deceive any insurance company or other person,
files a statement of claim containing any false, incomplete, or misleading information, may be guilty of a felony and subject to criminal and civil penalties.
                                                              CONTENTS INVENTORY FORM INSTRUCTIONS
1. Separate damaged and non-damaged items to protect repairable items from further damage.

2. Make copies of the Contents Inventory Form as needed for large losses or damages to multiple rooms Only record one (1) room per sheet in those cases.


3. Please set your printer to print on "Landscape Orientation" while printing this document.

4. Complete columns 1-8 for each item listed.

5. Column 8 - Replacement, Repair or Restoration Cost - should reflect the current value of the item. Report the exact cost. Do not round numbers up or down.
   To receive replacement cost benefits, you must submit the orginal replacement receipt.

6. Attach any documentation to show ownership and/or cost of the item. The following are accepted: original receipts, cancelled checks, warranty booklets, operating instructions and/or photographs.
   If an article is being repaired or cleaned, attach an estimate or invoice for the repair or cleaning service.

7. All receipts submitted must cross reference an item number on the Contents Inventory Form.
   To do this, write the item number from the Contents Inventory Form on the receipt next to the item to which it applies.
   Receipts that are not marked correctly will not be accepted.

8. For your records, make copies of all paperwork. Submit original paperwork for claim. If you would like originals returned note that with your submission

9. The Contents Inventory Form must be returned no later than 30 days after the date of loss.
   Return the form(s) to: PO Box 15339, Tallahassee, FL 32317.



                                                              Below is an example of how the form should be completed:



                                                              Contents Inventory Form
                                                                                                                                      Claim Number _________________________
Insured John Smith
                                                                                                                                      Claim Rep _________________________________
Date of Loss 01/01/02

Room Living Room


                                             TO BE COMPLETED BY INSURED                                                               TO BE COMPLETED BY CLAIM REPRESENTATIVE
                   2                     3                 4            5               6                  7                      8         9                 10                          11                12                      13

                                             Brand Name and   Purchased or                Date of Purchase Replacement, Repair                                    Adjustments to R/C **
          1 Quantity Description of Property Model Number     Obtained From Documentation Purchase Price   or Restoration Cost % Tax         R/C or Repair Cost   (depreciation)               Settlement        Maximum R/C Benefits

Item No            1 19" color tv            Zenith/sf5749w   Sears         B               12/02 - $175       $ 75 to repair
                                                              Camera
      1            1 35 mm camera            Canon AE1        Corner        O                6/02 - $275       $ 250 to replace
      2

				
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