3601 Haven Ave . Menlo Park . California 94025 . 650 780-4800
PERSONAL PROPERTY LOSS INVENTORY SHEET INSTRUCTIONS Thank you for taking the time to complete the attached Property Loss Inventory Form. These Instructions are provided to assist you in completing the form(s). Your attention in carefully completing the forms will assist us and avoid any possible delay in the replacement of your personal property. It is essential we receive all requested information promptly to expedite the resolution of your claim. For Every item that was damages or stolen, list each one on a separate line. Please complete the following to the best of your ability: ♦ Give a complete description of each item, including the following: o Type of item (i.e. television, toaster, vacuum cleaner, picture frame, etc.) include in the description, size, color, attachments and accessories as applicable. o List the brand name OR name of the Manufacturer (e.g., Sony, G.E., Eureka, etc) o List the Model Number for the item o List the Serial Number (if applicable) ♦ For clothing, list brand name, fabric and style individually by name or description. ♦ List ORIGINAL PURCHASE PRICE of each item (i.e., the amount you originally paid to purchase the item.) ♦ List the DATE OF PURCHASE of each item (i.e. month and year.) ♦ List the PLACE OF PURCHASE of each item (i.e. the name of the store and city/town where you made the purchase.) If the item was purchased by another individual or received/acquired as a gift, please list the name and last know address and telephone number of that individual. ♦ List METHOD OF PAYMENT for item (e.g., credit card, check, or cash). If the item was a gift, please note “gift”. ♦ Indicate if RECEIPT IS ATTACHED, or if other verifying documents are available, including operating manuals, personal photographs (before or after the loss) that show the damaged or stolen item, warranty cards, service receipts and tags, credit card receipts/statements, etc. Please include ORIGINAL or a legible copy of any documents. (** Please note: ANY ORIGINAL DOCUMENT MAILED TO US WILL NOT BE RETURNED). ♦ Indicate DESCRIPTION OF DAMAGE (e.g., Stolen, Smoke Damage, Water Damage, etc.) ***** PLEASE DO NOT WRITE IN SECTION MARKED “OFFICE USE ONLY” ***** Attach additional pages a s necessary to provide all requested information. PLEASE NOTE: Each page must be SIGNED AND DATED. In the case of a theft loss, all items listed on the INVENTORY must also be listed on the police report pertaining to the theft. An additional or supplementary police report must be filed for all items not listed in the initial police report.
Personal Property Claim Summary Sheet
Insured Name:______________________________________ Address: __________________________________________
Description of Property Purchase Price Purchase Date Purchase Location
Page _______ of ______ Pages
Policy Number: ____________________________ Claim Number: ____________________________ OFFICE USE ONLY
Receipt Attached
No
Manufacturer
Model
RCV
%
$
ACV
Sublimits
EXAMPLE EXAMPLE
1 2 3 4 5 6 7 8 9 10 I swear under penalty of perjury under the laws of the state of ____________ that the foregoing is a true and correct description of my personal property loss.
Sub - Total Deductible
Insured Signature: _______________________
Date: ________________
Total