Insurance Claim Form | Highline Electric Association.

Insurance Claim Form

Full Name

Phone

Address

City/Town

State/Province

ZIP/Postal Code

Date/Time of Loss

Location of Loss

City/Town

State/Province

What was the believed cause of damage?

Outage

Blinks

Surge

Other

Please explain incident:

On the date of loss was a call made to Highline Electric Association reporting the incident?

Yes

To the best of your knowledge, were there other people affected?

Yes

If yes, please explain:

What was damaged?

Estimated amount of damage:

Was it repaired?

Comments: