PROPERTY DAMAGE CLAIM REPORTING FORM

INSURANCE PROGRAM FOR FOSTER PARENTS 

(COMPLETE THIS FORM IF YOU ARE MAKING A CLAIM FOR DAMAGE TO YOUR PROPERTY)

1.	Foster Parent _________________________________________________________________

2.	Street Address ________________________________________________________________________________________

City ______________________________ State ________ Zip ______________ Telephone# ________________________

3.	Foster Parent License # _________________________________ 

4.	Name of Foster Child _________________________________________________________________
	
Foster Child Date of Birth ________________________________________    (OR) Age __________ Sex ___________

5.	SPECIFIC Date and time of incident __________________________________________________________________

6.	List of damaged property (use backside of this form as needed) ______________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

7.	Describe how property listed above was damaged _______________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

8.	Where can damaged property be seen? ______________________________________________________

9.	Estimated dollar amount of property damage __________________________________________________

10.	Has loss been reported to your insurance company? _____________________________________________________________

11.	If yes, name and phone # of person reported to _________________________________________________________________

	______________________________________________________		______________________________________
				Signature							       Date

	Failure to comply with the following provisions may exclude your claim from coverage:

		1.	Do not destroy, repair or dispose of damaged property until Risk Management 
            Division has given authority to do so.

2.	This form must be filled out and mailed DIRECTLY to the address shown below
            promptly and WITHIN 45 DAYS of the loss

RISK MANAGEMENT DIVISION
85 STATE HOUSE STATION
AUGUSTA, MAINE  04333

O:\WPFS\CLAIMS\CLAIM FORMS\FOSTER PARENT PROPERTY DAMAGE CLAIM FORM.DOC                                     Rev. 12/12

				     1-800-525-1252 or 287-3351