SRST Property Loss Form

"*" indicates required fields

Insured: STANDING ROCK SIOUX TRIBE

Department*

Date of Loss

Time of Loss

:

Insured Location

Name of Location

Location Address

Street Address City ZIP / Postal Code

Kind of loss (fire, water, theft, flood, wind, hail, lightening, other)

Description of Loss & Damage

Insured Contact Info

Claim Contact

Contact Email

Authorized By

Contact Phone