Student Loss Claim Form

The form below should be used by covered individuals to file a claim for items stolen/damaged while located in the chapter house. Please provide as much information as possible, including complete lists of impacted items, photos, receipts, etc.

Legal Name(Required)

First Last

Phone Number(Required)

Non-Edu Email(Required)

University(Required)

Date of Loss(Required)

If loss occurred over a break, list "winter break", "spring break", etc.

Details of Loss(Required)

Please provide as much detail as possible. Include cause and description of loss, a list of impacted items, cost of items, police report (if applicable), etc.

Attachments

Please upload pictures of any damaged items, a list of impacted items and their prices, receipts for replacements, etc.

Drop files here or

Max. file size: 128 MB.

Acknowledgements(Required)

I understand that all claims will be reviewed by the Esponda Associates staff prior to being processed.

I understand that Esponda reserves the right, but not the obligation, to choose to settle potential claims rather than process them as claims.

I understand that filing this claim does not guarantee that the claim will be approved.

I understand that failure to provide requested or required information may result in denial of coverage.

I understand that I have a $500 deductible which will be deducted from any reimbursement I may receive.

I understand that claims will not be paid upfront, or directly to the service provider, and will be processed as reimbursements only once I have submitted proof of the expense.

Signature(Required)

By signing below, I certify that the information provided is true and accurate to the best of my knowledge.

Date(Required)