ASI INVENTORY OF ITEMS - American Strategic Insurance
ASI INVENTORY OF ITEMS
Insured: _________________________ Date of Loss: _______________ Policy No.: ___________________ Claim No.: ______________
|Cancelled checks, repair bills, receipts and photographs should be attached to support your claim. Complete columns 1 through 10 on each item – If |To be completed by Company |
|unknown, put NA. Failure to comply with above will result in a delay in the handling of your claim. | |
(1)
Item |
(2)
Quantity |
(3)
Description of Item
(Type, name, model, year, serial no.) |
(4)
Where Purchased
(Name and Address) |
(5)
Age
Of
Item |
(6)
Date of
Purchase
(Mo–Yr.) |
(7)
Method of
Payment
(Cash/Cr.) |
(8)
Receipts
Available? |
(9)
Original
Cost
|
(10)
Replacement
Cost |
Ins.
Repl.
Cost |
Betterment
Or
Depreciation
% $ |
Adjusted Value | |1 | | | | | | | | | | | | | | |2 | | | | | | | | | | | | | | |3 | | | | | | | | | | | | | | |4 | | | | | | | | | | | | | | |5 | | | | | | | | | | | | | | |6 | | | | | | | | | | | | | | |7 | | | | | | | | | | | | | | |8 | | | | | | | | | | | | | | |9 | | | | | | | | | | | | | | |10 | | | | | | | | | | | | | | | | | | | | |TOTALS | | | | | | | |
Remarks: ____________________________________________ Repairs to Dwelling or Contents: ____________________________________
____________________________________
CONCEALMENT OR FRAUD
Coverage is not provided for any insured who has intentionally concealed or APPLICABLE IN FLORIDA
misrepresented ANY material fact or circumstance relating to this claim. Any person who knowingly and with intent to injure, defraud, or
deceive any insurance company files a statement of claim
This inventory form becomes a part of any Proof of Loss filed on this claim. containing any false, incomplete or misleading information is
guilty of a felony of a third degree.
_______________________ __________________________ __________________
Insured’s Signature Insured’s Signature Signature Date 3/16/05
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