Home Insurance – Report a Claim Policy Number: Your Name: First Last Contact Person:Whom should the adjuster call to settle your claim?Name: Home phone:Work phone:Email:* Best Time to Call: Authority Contacted:Police/Fire department: Report number: Claim Information:Date of loss: Location of claim: Cause of Loss:FireHailLightningSmokeTheftVandalismVehicleWaterWindOther-describe belowDescribe Your Damages/LossEmergency services needed:Temporary Shelter Required? Yes No Windows Required Boardup? Yes No Other? Persons Injured:Name and address: Phone number: Nature of Injuries: Cause of Injuries: Comments and/or Other InformationHow Would You Like us to Reply To Your Request: Mail Fax Email PhoneThis field is for validation purposes and should be left unchanged. Insurance coverage will not be canceled, bound or modified without a written confirmation from Ledbetter Insurance Agency.