Orange and Rockland Utilities, Inc. Claim Department
Rockland Electric Company PO Box 1008
Spring Valley, NY 10977-9911
Claim Form claims@oru.com
Fax: 914-925-9250
Your Name
Mr.
□
Last Name First Name
Mrs.
□
Mailing
Ms.
□
Address
House No. and Street
Owner
□
Tenant
□
Business
Town State Zip
Name
Business or Company Name (If Applicable)
Your
Contact Info.
(Area Code) Best Contact Number
(Area Code) Alternate Telephone Number
Email
Account No.
Account Number
Location of
Incident
Address City State
Electric
□
Date and
Loss is Gas
□
Time of Loss
Related to:
Vehicle
□
Date Time
Weather
Conditions
Rain □ Wind □
Lightning □
Snow □ Fair □
Other
Briefly describe the events causing the damage/loss or personal injury. If known, include the name of any company employees or contractors involved.
List the items damaged: YOU MUST INCLUDE MAKE, MODEL NUMBER and DATE OF ORIGINAL PURCHASE and PURCHASE PRICE. Enclose a written repair bill
or estimate for each damaged item. If items are not repairable, enclose a statement from a repairman stating the cost to repair them would exceed the cost to replace
them along with a copy of the original purchase receipt or a written estimate of the replacement cost. Depreciation is taken on replacement items. (Attach additional
pages if necessary)
____
__________________________________________________________
Demand Amount Sought $ _____________________
Have you made a claim for this loss against your insurance carrier?
Yes
□
No
□
If yes, please provide: INSURANCE COMPANY NAME: ___________________POLICY NUMBER: ____________________
Notice: Any person knowingly and with intent to defraud any insurance company or other persons, 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, subject to criminal prosecution
and civil penalties. Submission of this form does not necessarily guarantee any payment.
I CERTIFY THE ABOVE STATEMENTS ARE TRUE AND ACCURATE.
CLAIMANT'S SIGNATURE
DATE
click to sign
signature
click to edit
![]()
