Submit a Residential Claim for [Event Name]

If you lost power for more than 48 consecutive hours starting on August 4, 2020, you can file a claim to be reimbursed for spoiled food or prescription medication.

Thank You for Submitting Your Claim

An investigator will review your claim and contact you with a disposition as soon as possible. Please allow us approximately 30 days to complete our investigation.

If you have any questions, please contact us.

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ALL FIELDS ARE REQUIRED, UNLESS OTHERWISE NOTED

Requirements for Food Spoilage Claims

Proof required for food losses of $235–$540. Examples of acceptable proof of loss include: cash register tapes, store or credit card receipts, canceled checks, or photographs of spoiled items.

Please itemize all losses.

Proof is not required for food losses under $235.

Requirements for Prescription Medication Loss Claims

Proof required for all prescription medication losses. Examples of acceptable proof of loss include pharmacy prescription labels or pharmacy receipts identifying the medicine.

We may request authorization to verify the loss of prescription medicine.

Reimbursement for prescription medicine is not included in the $540 maximum for food spoilage.

Name

Address

Apt/Suite (if applicable)

City

State

Zip Code

Daytime Phone Number

Account Number

Please let us know when you lost power due to the Christmas Eve storm.

Outage Start Date

Outage End Date

Please provide details about the item(s) you lost during the outage. Please fill at least one row. If you have more than 10 items, please create and attach your itemized list.

ITEM 1

Type of Item

Quantity

Cost Per Item

Your total dollar amount of loss is calculated based on your list of items.

Total Item(s)

Total Dollar Amount of Loss

$0.00

Supporting Documents

Please provide proof of all prescription medication losses and food losses totaling $235–$540. Proof is not required for food losses under $235

Accepted file types: JPG, JPEG, PNG, GIF, PDF, DOC, DOCX, XLS, XLSX
Maximum number of attachments: 10
Individual file size limit: 5MB
Total file size limit: 15MB

Drop supporting files here Optional Or select from your computer

Please allows us approximately 30 days from the date of this correspondence to complete our investigation and provide you with a determination.

Your electronic signature is the same as your handwritten signature and is certification of the truth and accuracy of the information submitted. Your signature confirms that all of the information provided on this form is true and accurate to the best of your knowledge and represents your actual losses.

Signature

Date

Error: This field is required.