Personal Property Instruction Sheet

We need your help to process your claim. We may be unable to process your claim until
you send us this completed information.

Please:
1. Complete columns 1-7 of the Personal Property Claim List. Accurate and detailed
information is necessary to properly value your damaged personal property. Please refer to
the Personal Property Claim List Example for instructions.

If you wish, you can also fill out the sheets electronically by launching this document

2. Thoroughly review, sign and date the Personal Property Claim List.

3. Provide original documentation of ownership for the damaged items. The following are
examples:

a. Receipts / layaway slips f. Bill of Sale / Invoice

b. Credit card statements g. Photographs (Items may be in the background)
c. Cancelled checks h. Owner’s manuals / Instruction books
d. Remote Controls i. Appraisal completed prior to the loss
e. Warranty cards j. Original boxes

(We understand that you may not have documentation for all items that were damaged
or stolen.)

4. Once you have completed the Personal Property Claim List, please sign and return the
forms along with the documentation of ownership to the following address:

Fortegra, Claims Service Center

PO Box 45153, Jacksonville, FL 32232

If you complete the forms electronically, please Email the forms and proof of ownership to:
storageclaims@fortegra.com

Please be aware that submission of the requested information does not infer or imply
coverage for the items submitted. All insurance policies have coverage that is subject to
limitations, exclusions and conditions. For specific information on these limitations,
exclusions and conditions please refer to your policy. Please see the proceeding pages for
important information.
 STATE SPECIFIC FRAUD WARNINGS
Alaska Residents: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing
false, incomplete, or misleading information may be prosecuted under this title.
Arizona Residents: For your protection Arizona law requires the following statement to appear on this form. Any person who
knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Arkansas and New Mexico Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit
or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal
penalties.
California Residents: For your protection California law requires the following to appear on this form: Any person who knowingly
presents false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and
civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading
facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the
Department of Regulatory Agencies.
Delaware and Idaho Residents: Any person who knowingly and with intent to injure, defraud, or deceive an insurer files a statement of
a claim containing any false, incomplete, or misleading information is guilty of a felony.
District of Columbia and Washington DC Residents: WARNING: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer
may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Hawaii Residents: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss
or benefit is a crime punishable by fines or imprisonment, or both.
Indiana Residents: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false,
incomplete, or misleading information commits a felony.
Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of
claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
Louisiana and Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss
or benefit or knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
Tennessee and Virginia Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and a denial of insurance benefits.
Maine Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Minnesota Residents: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an
insurer is guilty of a crime.
New Hampshire Residents: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of
claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as
provided in R.S.A. §638:20.
New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is subject
to criminal and civil penalties.
New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not
to exceed five thousand dollars and the stated value of the claim for each violation.
Ohio Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma Residents: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of
claim or application containing any materially false information or conceals, for the purpose of misleading, information concerning any
material fact may be guilty of an insurance fraud, which is a crime, and may be subject to prosecution.
Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties.
Texas, West Virginia and Alabama Residents: 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, or any combination thereof.
All Other States: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit may be guilty of a
crime and may be subject to fines and confinement in prison.
9-10-12
Insured: _____________________________ PERSONAL PROPERTY CLAIM LIST Page: ____ Of: ____

Date of Loss: ______________________ (Complete unshaded area only)

Claim #: __________________________
1 2 3 4 5 6 7 Do not write in this area
DESCRIPTION OF ITEM WHERE PURCHASED PURCH ORIGINAL PAYMENT METHOD REPLACEMENT REPLACEMENT DEPR. LIMIT
NO. Make, Model, Serial # (if applicable) City & Store (Financed ?) MO. YR. COST Check-Cash-Credit SOURCE COST % $ CLAIM

10

11

12

13

14

15
This Personal Property Inventory of ________ page(s) accurately states my/our loss resulting
from _________________ which occurred on ___________ . The information I/we have provided for this SUB-TOTALS
contents inventory is true and correct to the best of my/our knowledge. SALES TAX %
GRAND TOTAL
________________________________ __________ _________________________ ________
Signature Date Signature Date
**********Please make a copy of this form for your records**********
Insured: Your Name EXAMPLE ONLY Page: __1__ Of: __1__
Date of Loss: 10/01/XX PERSONAL PROPERTY CLAIM LIST
Claim #: 1234567 (Complete unshaded area only)
1 2 3 4 5 6 7 Do not write in this area
DESCRIPTION OF ITEM WHERE PURCHASED PURCH ORIGINAL PAYMENT METHOD REPLACEMENT REPLACEMENT DEPR. LIMIT
NO. Make, Model, Serial # (if applicable) City & Store (Financed ?) MO. YR. COST Check-Cash-Credit SOURCE COST % $ CLAIM

1 Sony 27" TV JX3954 Amelia / Best Buy 06 04 329.99 Credit Best Buy 279.99

2 Phillips DVD DVP642 Eastgate / Walmart 10 03 74.99 Cash Walmart 59.99

3 Sectional Couch Eastgate / Rhodes 05 01 1499.99 Credit Rhodes 1299.99

4 My shirts Various Various 200.00 Cash Various 200.00

5 My pants Various Various 400.00 Cash Various 400.00

6 Dishes Beechmont / Target Various 150.00 Cash Target 150.00

7 20" Gold 14kt Necklace Eastgate / Sears 02 02 124.99 Credit Sears 149.99

10

11

12

13

14

15
This Personal Property Inventory of ___1_____ page(s) accurately states my/our loss resulting
from Fire which occurred on 10/01/XX . The information I/we have provided for this SUB-TOTALS 2539.96
contents inventory is true and correct to the best of my/our knowledge. SALES TAX % 177.80
GRAND TOTAL 2717.76
________________________________ 10/15/XX _________________________ ________
Signature Date Signature Date
**********Please make a copy of this form for your records**********