Notice Of Plate Glass Loss (Spanish)
The notice of plate glass loss details the circumstances and description of loss. Included is an estimate for lowest replacement cost by a glazier.
PDF (59KB)
Forms Property & Casualty
BEQ-6B (2020) Basic Earthquake Policy - Condo Unit Policy
A California Earthquake Authority (CEA) policy which provides basic earthquake coverage for condominium owners. Sold and serviced by participating insurance companies.
PDF (509.474KB)
Policy Forms
Sworn Statement In Proof Of Loss (w/Subrogation) (Spanish)
A notarized statement of the money claimed for a loss under a property coverage policy, which includes giving insurer the right to recovery.
PDF (75KB)
Forms Property & Casualty
Affidavit-Lightning Losses (Spanish)
This affidavit is filled out by a service provider who inspects a property and certifies lightning damage as the sole source of the loss. A notorized signature and witnesses are required.
PDF (50KB)
Forms Property & Casualty
CEA 04A Endorsement Coverage for Breakables
A sample California Earthquake Authority (CEA) endorsement which provides a optional coverage to forms BEQ-3B, BEQ-3C, BEQ-6B, and BEQ-4B. Sold and serviced by participating insurance companies.
PDF (657.99KB)
Policy Forms
Manufactured (Mobile) Home/Travel Trailer Worksheet FEMA Form 086-0-17 (4/17)
This form is used by the adjuster to record information to determine the replacement cost and actual cash value of a manufactured (mobile) home.
PDF (394KB)
Forms Flood
Customer's Claim & Affidavit (Spanish)
Damage to customer's property is included under a commercial general liability policy; this form describes items lost, seller, purchase date and depreciation. The claim amount is submitted with signature of customer and adjuster.
PDF (61KB)
Forms Property & Casualty
Subrogation Receipt (Spanish)
A subrogation receipt is signed by the insured upon payment of a claim, and assigns the insurer to the right to recovery for the loss.
PDF (28KB)
Forms Property & Casualty
Reservation Of Rights Letter (Spanish)
The reservation of rights letter notifies the policyholder that the insurer reserves the right to deny coverage of a claim, in whole or part, pending outcome of a claims investigation.
DOC (57KB)
Letters
Claim Acknowledgement Letter (Spanish)
A basic MS Word template letter sent as a best practice for the protection of all parties involved. The letter acknowledges receipt of the claim and requests contact with the insured or claimant.
DOC (51KB)
Letters
Release & Authorization Of Payment (Spanish)
Used as a general release form which is signed by insureds and specifies payment to settle a claim. The release contains a statement that, as a condition of the settlement, prevents any further claim or legal action against the insurer for the loss event.
PDF (40KB)
Forms Property & Casualty
Release And Trust Agreement (UM/UIM PD) (Spanish)
A release form signed by an insured when making an uninsured motorist or underinsured motorist claim involving property damage.
PDF (75KB)
Forms Property & Casualty
