Statement of Loss For Churches | Hurricane Ida Church #(Required) Church name(Required) Church address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Was an insurance claim filed?(Required) Yes No If claim was filed, enter claim #(Required) Has an adjuster been to the church and provided a statement of loss?(Required) Yes No If adjuster has been to the church, what is the replacement cost value on the statement of loss?(Required) If no, do you have an estimated time of when the adjuster will review your case? Have you had a contractor look at the damage and have your received an estimate? Yes No If yes, how much is the estimate and what repairs are needed? Insurance payment received. *for those who have already received payment.The insurance company will provide some payment. How much can the church raise?(Required) How much grant or additional funding might you request?(Required) Trustee Chair Name *please enter if knownTrustee Chair Email Address * please enter if knownPlease provide the name, phone number and email address of the church person handling the claimName(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) For more information, please contact: Alexa Taylor Insurance and Benefits Manager Phone: 732-359-1038 Email: ataylor@gnjumc.org
