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.