LOSS PROTECTION CLAIM Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. was Date work Please complete the form below to submit a Loss Proctection Claim online. We recommend that you have electronic files (pictures, receipts, etc...) in an easy to find location on your computer. It will speed up the submission process. Name *FirstLastService AddressAccount NumberPhone *Email *Description of the leak and steps taken to repair: *Leak occurred in: (check one)*Internal Water LineExternal Water LineExternal Irrigation Line*Please see the Service Contract(s) for definitions of line types. Date Leak was DiscoveredDate Leak was RepairedPlease upload receipts for repair work done. For self repair, receipts and pictures of repair are required. Drag & Drop Files, Choose Files to Upload Submission DateAcknowledgement * Clear Signature I certify that the information provided in this form is true, and that reimbursement for any eligible claim is subject to the appropriate Service Contract Agreement. I also certify that I have authority to make a claim for this account.Email *Submit
