Sedgwick Claims Management Services, Inc.

PO Box 14514
Lexington, KY 40512-4514

Phone: 877-878-6730 Option 2

Fax: 503-412-3990
July 22, 2019

Amber Miner
15808 Hesperian Blvd Unit 66
San Lorenzo, CA 94580

RE: Insured : Amber Miner

Date of Loss : 07/05/2019
Type of Loss : Burglary
Claim Number : 30193100010-0001

Dear Amber Miner ,

This letter acknowledges receipt of your claim. Sedgwick is the claims administrator for New Hampshire
Insurance Company, the insurer for your storage insurance. I have been assigned to the above referenced
claim. All future correspondence should reference your claim number listed above and be sent to PO
Box14514 Lexington, KY 40512-4514.

Your certificate of storage insurance provides coverage up to a maximum of $3,000 subject to a $100
deductible, as well as the terms and conditions of the certificate. In order to expedite the handling of your
claim, please provide the following:

1. Photographs: If available, please provide photographs depicting any physical damage to the
storage unit or your lock.

2. Police Report: Please report the burglary to the police as required by the certificate of insurance.
A copy of the police report will assist us in evaluating the claim. At your request, we will order a
copy of the report from the appropriate police department but we will need the attached Police
Detail Report completed and returned to us. Once requested, the report may take several weeks
to receive.

There are times when it may be quicker for you to obtain the report and send directly to us. If
you incur a fee, you may submit that invoice for reimbursement.

3. Inventory Sheet (attached): Please complete the enclosed Inventory Sheet in its entirety. Be
sure to include specifics such as brand, model, size, condition of item, original price, date and
location of purchase.

!C26876358.339-2618!
 4. Proof of Interest in the Property: Please provide us with the appropriate documentation which
shows you own or have an interest in the damaged or stolen property. This may be original
receipts, photographs that show the item in the background, owners’ manuals, bank records,
financial records, credit card records, reprinted store receipts, warranty papers, remote controls
or repair history/invoices as well as retailer account history.

We ask that you return the requested documentation within the next 30 (thirty) days to the address
indicated above. You may also send via e-mail to Storageclaims@sedgwickcms.com and we will have the
information available to us within 24 hours. Attachments of the following file types can be accepted: DOC,
GIF, HTM, HTML, JPG, PDF, RTF, or TIF. The maximum size capacity is 25 megabytes per email.

To ensure documentation is matched to your claim, please include your claim number in the subject line of
the email. At this time, Sedgwick cannot accept documents via Dropbox™.

We look forward to receiving the requested information and working toward the conclusion of your claim.
Should you have any questions, please do not hesitate to contact me.

Sincerely,

Alyssa Thiessen
Property Claims Representative
Sedgwick
Direct Line: (503)412-3972
Toll Free: 877-878-6730, Option 2 ext. 23972

For more information regarding the Orange Door Storage Insurance Program, please visit
www.orangedoorstorageinsurance.com

Please review the attached Fraud Statement that is applicable to your state

!C26876358.339-2618!
Sedgwick
P O Box 14514
Lexington, KY 40512-4514

Phone: 877 878-6730, Option 2

Fax: (503)412-3990

FRAUD STATEMENTS

Please read the following fraud language applicable to your state. This language is included with your claim forms
and is part of your claim file.

Alabama
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or
confinement in prison, or any combination thereof.

Alaska
A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing
false, incomplete or misleading information may be prosecuted under this title.

Arizona
For your protection Arizona law requires the following statement to appear on this form, any person who knowingly
presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Arkansas
Any person or entity who willfully and knowingly makes any material false statement or representation for the purpose
of obtaining any benefit or payment, or for the purpose of defeating or wrongfully decreasing any claim for benefit or
payment or obtaining or avoiding workers compensation coverage or avoiding payment of the proper insurance
premium, or who aids and abets for either of said purposes, under this chapter shall be guilty of a Class D felony.

California
For your protection California law requires the following to appear on this form. Any person who knowingly presents
false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in
state prison.

Colorado
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting
to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado division of insurance within the department of regulatory agencies.

Delaware
Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony.

!C26876358.339-2618!
District of Columbia
WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer
or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if
false information materially related to a claim was provided by the applicant.

Florida
Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete, or misleading Information is guilty of a felony of the third degree.

Hawaii
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both:" The absence of such a warning in any application or
claim form shall not constitute a defense to a charge of insurance fraud under this section.

Idaho
Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement containing
any false, incomplete, or misleading information is guilty of a felony.

Indiana
Any person who knowingly, and with intent to defraud an insurer, files a statement of claim containing false, incomplete
or misleading information commits a felony.

Kentucky
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.

Louisiana
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.

Maine
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes
of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Maryland
Any person who knowingly or willfully presents a false or fraudulent claim for payment for a loss or benefit or who
knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject
to fines and confinement in prison.

New Hampshire
Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim
containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud
as provided in R.S.A. 638.20.

New Jersey

!C26876358.339-2618!
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal
and civil penalties.

New Mexico
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal
penalties.

New York
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or 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, and shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.

Ohio
Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania Section
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or 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 and subjects such
person to criminal and civil penalties.

Rhode Island
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.

Tennessee
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Utah
Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or
fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for
health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state
prison. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Washington
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

!C26876358.339-2618!
West Virginia Section
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison

All Other States:

If you live in a state other than one mentioned above, the following statement applies to you:

Any person who knowingly, and with intent to injure, defraud or deceive any insurer or insurance company, files a
statement of claim containing any materially false, incomplete, or misleading information or conceals any fact material
thereto, may be guilty of a fraudulent act, may be prosecuted under state law and may be subject to civil and criminal
penalties. In addition, any insurer or insurance company may deny benefits if false information materially related to a
claim is provided by the claimant.

!C26876358.339-2618!
Sedgwick
P O Box 14514
Lexington, Ky 40512-4514

Phone: (503)412-3972
Fax: (503)412-3990
Police Detail Form

RE: Insured: Amber Miner

Date of Loss: 07/05/2019
Type of Loss: Burglary
Claim Number: 30193100010-0001

In order for Sedgwick to request a police report on your behalf,

please complete the below information and return to the
Sedgwick Examiner.

Police Department Name: San Leandro Police Department

_____________________________

Police Report Number: 19-30061

______________________________

Reporting Officer Name: Officer Pizzicho #379

______________________________

Person that Filed Report: Amber Miner

______________________________

Date Report Filed: 07/09/2019

_______________________________

I, Amber Miner , request Sedgwick obtain the police records pertaining to the above loss. I understand
that the police department in some jurisdictions may require a signed authorization by me in order to
release the report. In the event written authorization is required, I understand that Sedgwick may forward
an additional form for signature.

FOR YOUR PROTECTION STATE LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM:
Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of
a crime and maybe subject to fines and confinement in state prison.
Amber Miner 08/09/2019
Printed Name: ____________________________________________Date:____________________

Signature: ________________________________________________

Please return completed form to Sedgwick examiner:

Sedgwick
Alyssa Thiessen
Property Claims Representative
P O Box 14514
Lexington, KY 40512-4514
Direct Line: (503)412-3972
Toll Free: 877-878-6730, Option 2, ext. 23972

For more information regarding the Orange Door Storage Insurance Program, please visit:
www.orangedoorstorageinsurance.com
!C26876358.339-2618!
 Orange Door Storage Insurance
Mail claim forms to Sedgwick: PO Box 14514 Lexington KY 40512-4514
Claim # 30193100010-0001 *Documentation Email: StorageClaims@sedgwickcms.com
*Size and file type limitations apply
Item
No Detailed Description of Property Original Date of Condition Where Method of Receipt/Invoice
(Brand Name, Model Number, Cost Quantity Purchase (Very Good, Purchased Payment Included?
Serial Number, Size, Color, etc)
Good, Fair)

General Electric Toaster Oven. M-4. 782323. 12

Inch. White Credit Card Yes
$39.99 1 02/07/2008 Good Sears No
(Example Only)
Yes
1
No
Yes
2
No
Yes
3
No
Yes
4
No
Yes
5
No
Yes
6
No
Yes
7
No
Yes
8
No
Yes
9
No
Yes
10
No

Signature: ______________________________________ Date: _______________________

 Orange Door Storage Insurance
Mail claim forms to Sedgwick: PO Box 14514 Lexington KY 40512-4514
Claim # 30193100010-0001 *Documentation Email: StorageClaims@sedgwickcms.com
*Size and file type limitations apply
Item
No Detailed Description of Property Method
Original Date of Condition Where Receipt/Invoice
(Brand Name, Model Number, of
Cost Quantity Purchase (Very Good, Purchased Included?
Serial Number, Size, Color, etc) Payment
Good, Fair)

General Electric Toaster Oven. M-4. 782323. 12

Credit Yes
Inch. White
$39.99 1 02/07/2008 Good Sears Card No
(Example Only)
Yes
1
No
Yes
2
No
Yes
3
No
Yes
4
No
Yes
5
No
Yes
6
No
Yes
7
No
Yes
8
No
Yes
9
No
Yes
10
No

Signature: ______________________________________ Date: _______________________

 Orange Door Storage Insurance
Mail claim forms to Sedgwick: PO Box 14514 Lexington KY 40512-4514
Claim # 30193100010-0001 *Documentation Email: StorageClaims@sedgwickcms.com
*Size and file type limitations apply
Item
No Detailed Description of Property Method
Original Date of Condition Where Receipt/Invoice
(Brand Name, Model Number, of
Cost Quantity Purchase (Very Good, Purchased Included?
Serial Number, Size, Color, etc) Payment
Good, Fair)

General Electric Toaster Oven. M-4. 782323. 12

Credit Yes
Inch. White
$39.99 1 02/07/2008 Good Sears Card No
(Example Only)
Yes
1
No
Yes
2
No
Yes
3
No
Yes
4
No
Yes
5
No
Yes
6
No
Yes
7
No
Yes
8
No
Yes
9
No
Yes
10
No

Signature: ______________________________________ Date: _______________________