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Claim Received


[ninja_forms_field id=67],

Thank you for completing the Property Damage Claim Form. You will receive a confirmation letter in the mail within the next 7-10 business days.  Should you have any questions, please contact us at (877) 412-5277 or

You may retain a copy of your claim submission for your records by clicking the button below:

You may press “Ctrl+P” or “Cmd+P” at any time to print a copy of this claim form submission for your records.

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Question Response
Full name: [ninja_forms_field id=67]
Property address: [ninja_forms_field id=151]
[ninja_forms_field id=70], [ninja_forms_field id=71] [ninja_forms_field id=72]
Current mailing address (if different): [ninja_forms_field id=173]
[ninja_forms_field id=75], [ninja_forms_field id=172] [ninja_forms_field id=77]
Day telephone: [ninja_forms_field id=79]
Evening telephone: [ninja_forms_field id=80]
E-mail: [ninja_forms_field id=81]
Customer ID: [ninja_forms_field id=279]
Incident information
Date of leak/burst: [ninja_forms_field id=84]
Flushmate serial number: [ninja_forms_field id=85]
Amount of property damage claimed: [ninja_forms_field id=86]
File Upload: [ninja_forms_field id=155]
Have you received reimbursement: [ninja_forms_field id=160]
Total amount of payments/reimbursements: [ninja_forms_field id=91]
Source of payments/reimbursements (optional): [ninja_forms_field id=93]
File Upload: [ninja_forms_field id=161]
Signature of claimant: [ninja_forms_field id=95]