Part 1: Claimant Information

• Last Name:
• First Name:
• Date:

• Address:
• Email:
• Phone:

Part 2: Statement of Claim

LTIC Policy Number:

• Property Owner:
• Property Address:

• City:
• County:
• State:
• Zip:

Explanation for the claim:

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.