Statement of Damages Online Form

Statement of Damage

Name:(Required)

First Last

Email:(Required)

Phone:(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Incident:(Required)

Approximate time of Incident:(Required)

Location of Incident - Physical Address:(Required)

Cause of Damage:(Required)

Damaged Item:(Required)

Original Cost of Item(Required)

Age of Item(Required)

Is Item Repairable?(Required)

Estimated Cost to Repair

Estimate Provided By:

Actual Cost

Receipts may be request upon submission of this form

Repairs Made By:

Receipts may be requested upon form submission.

Additional Remarks:

Digital Signature:(Required)

First Last

Printed name will serve as electronic signature

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