Lender-Placed
Hazard or Flood Claims

Lender Placed Hazard or Flood Claims

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
MM slash DD slash YYYY
How was damage / loss discovered?
Loss Type
Reporting Party
Name*
Phone Number*
Email Address*
Contact Person
Name*
Home Phone Number*
Work Phone Number
Email Address*
File
Max. file size: 2 MB.
File
Max. file size: 2 MB.
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.”