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102-1228 (04/13/15)
To report a claim for damage to your property that you believe is related to the April 3, 2015 Appliance Park fire, please
complete this form and return via email, fax, or mail as shown below. Our Claims Team will begin reviewing your claim once
this completed form has been received in our office.
GE is defending itself in a lawsuit in which the plaintiff is asking the court to let her represent a class in which you may be a
potential class member. We cannot discuss your claim with you if you’ve already asked a lawyer to represent you regarding
your claim. If you’ve already asked a lawyer to represent you, please ask your lawyer to contact us to discuss your claim.
WHAT TO DO
1. Read this form carefully.
2. Provide information required below.
3. Sign and date this form.
4. Make a duplicate of this completed form for your records.
5. Return the completed form to Electric Insurance Company® by any of the methods shown below.
PROVIDE YOUR CONTACT INFORMATION
PROVIDE DETAILS ABOUT YOUR CLAIM
Provide a specific description of the damage you are claiming was done to your property. We encourage you to provide photos of the
damage to support your claim. Please note that all claims are subject to investigation and physical inspection.
READ AND SIGN BELOW
Please read the following statement. By signing and dating this form you agree that the foregoing information you provided is a true
statement of the cause of this loss; you are not represented by a lawyer regarding your claim; and you understand that you have the
right to discuss your claim with your own lawyer, and that GE encourages you to seek the advice of your own lawyer.
Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any
materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime.
Your Name: _______________________________________________________________ (Please print)
Your Signature: ___________________________________________________________ Date: _______________________
FORM SUBMISSION
Submit this signed and dated form to Electric Insurance Company by any of the following methods:
FAX EMAIL UNITED STATES POSTAL SERVICE
978.236.5800 [email protected]
Electric Insurance Company Attn: Claims Department 75 Sam Fonzo Drive Beverly, MA 01915
Remember to keep a copy of this completed form for your records.
Name: Today’s Date:
Street: Phone # 1:
City: Phone # 2:
State: Email:
ZIP:
Appliance Park Fire First Notice of Loss Claim Form
Electric Insurance Company 75 Sam Fonzo Drive l Beverly, MA 01915 888.456.7445 l ElectricInsurance.com
