Loss of Use Claim Form
Submit details and supporting documents for a loss of use claim. Please provide accurate information about the affected asset, the time it was unavailable, and any related expenses.
Claimant and Claim Basics
Claimant full name
*
First Name
Middle Name
Last Name
Contact phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Preferred contact method
*
Phone
Email
Policy or claim reference number (if available)
Date loss of use started
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Brief description of what caused the loss of use
*
Affected Asset and Loss Details
Type of affected asset
*
Vehicle
Rental property
Other
Make/model or property identifier
Date the asset became unavailable
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected or actual end date of loss of use
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Was a replacement rental or alternate accommodation used?
*
Yes
No
Total out-of-pocket loss of use expenses
Documentation and Submission Details
Supporting Documents
*
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Additional Notes
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