Coastal Association Management

Property*

The Owner's Information:

First & Last Name*

Email*

Phone*

Street Address*

City*

State*

Zip*

The Tenant's Information:

First & Last Name*

Email*

Phone*

Street Address*

City*

State*

Zip*

Person who is claiming personal injury:

Owner

Tenant

Guest

First & Last Name*

Address*

Email*

Current Condition*

Was this weather related? Yes No

If yes, please explain

Was the person a child? Yes No

Approx age of the person?

Guardian or contact for the person

Witness Information

Name

Email

Phone

Property Claim Type

Is the property inhabitable? Yes No

Has a restoration company been contacted? Yes No

If so, which company

Date of Claim

Approximate Time of Claim

Claim Being Reported by

Detailed Summary of Occurrences

Any other details or comments

Are you filing this report for record purposes only? Yes No

Report a Claim