08/04/2021

RE:      Status Update

Insured : Melissa Ramos

Claim No : ESPR067768
Date of Loss : 02/10/2021
Extra Space Location : 24700 Mission Blvd. Hayward, CA 94544, Unit C123B
Carrier : Occidental Fire & Casualty Insurance of North Carolina
Policy Limit : ExtraSpace - 2K

Dear Melissa Ramos:

American Claims Management, Inc. is the third-party administrator for Occidental Fire & Casualty Company of North Carolina regarding
the above-mentioned claim.   

Currently, we are still waiting for your completed personal property inventory form. As of today, we have not received this. If the
requested information and supporting documents are not received within 30 days, we will inactivate our file.    Our file may be re-opened
upon receipt of the requested information and documents, provided it is within the 3 year statute of limitations applicable to the claim.

The completed form should be returned to us via mail, email or fax. Please note that you can obtain status of your claim by
accessing our website at:
portal.acmclaims.com/secureforms2/extraspace
All the information required to access your claim is noted in the header of this letter. 

If you have any questions, please contact the undersigned at (800) 423-6071 x 4553.

Sincerely,

Brian Atkins
Extra Space Claims Adjuster
batkins@acmclaims.com
Phone: (800)423-6071 x 4553
Fax: (760) 827-4081

For your protection California law requires the following to appear on this form. Any person who knowingly presents a 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.    Please be aware that
in the event you disagree in whole or in part, with our position of denial, you may have the matter reviewed by the California
Department of Insurance, Claims Service Bureau, 11th Floor, 300 South Spring Street, Los Angeles, CA 90013, (800)-927-4357.
Personal Property Inventory Form/ Sworn Statement In Proof Of Loss
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. 

Insured : Melissa Ramos

State : CA
Date of Loss : 02/10/2021
Adjuster : Brian Atkins
Claim Number : ESPR067768
Unit Number : C123B
Claim Type : STO - Burglary/theft/robbery ? other
Policy Limit : ExtraSpace - 2K

Item # Brand Model# Item How was Quantity Age in yrs Age in Pre-Loss Cost to Can Item
Descriptio Item months Condition Replace Be
n Damaged? Pre-Tax Cleaned or
Repaired?
Use Key $500
example Sears XYZ Refrigerator Below 1 10 2 Average Yes or No
 1 Gucci 808307 Belt Stolen 1 2 5 Like new $468 No
Sac Stolen $1350
Saint MNG
2 Laurent Lou Purse 1 1 4 Like new No
Portable Stolen $40
VGP- Vlogging
3 SunPack LED Kit 1 5 New No
Travel Stolen $129
Photo
Savage Bt01511 Back
4 universal 2 - KT Drop Kit 1 5 New No
Box Of Stolen $360
New
Clothes,
Floral
Shirts,
Floral
5 Dazz Skirts      30 4 New No
18V Stolen $80
7Cordles Stalwart Like
6 Sears s Drill 1 7 New No
Box of Stolen $90
New
Clothes,
Invoice Pants,
7 Hena 5570 Vests 55 3 New No
Box of Stolen $165
New
Clothes
Womens
Winter
8 Dynamic 50934 Jackets 30 7 New No
Counter Stolen $159
Fit Bill
Detector
/ Money Like
9 G Star UV/MG Counter 1 4 New No
Go Pack Stolen $50
3 Tool Like
10 Sears Drill Drill 1 6 New No
Green Stolen $60
and
black
Powered
Inverter
Ryobi Generat Like
11 Sears 150 Watt or 1 6 New No
12
 13
14
15
16
17
18
19
20
Do you have receipts? (yes or no) __________________________

Please provide current address:    22310 City Center Drive, Hayward Ca

94541_______________________________________________________________

NOTE: IF ADDRESS IS NOT CURRENT, POST OFFICE WILL NOT FORWARD CHECKS

By signing this form you agree that said loss did not originate by any act, design or procurement on your part; nothing has been done to violate the
conditions of the policy, or render it void; no property saved has in any manner been concealed, and no attempt to deceive the said company, as to the
extent of said loss, has in any manner been made.    Any other information that may be required will be furnished and considered a part of this proof.

Insured's Signature   Date  8/30/21

Personal Property Inventory Form/ Sworn Statement In Proof Of Loss

Instructions:    You have just suffered a loss to your personal property that will require some time to properly list.   
These instructions and the Personal Property Inventory Forms will hopefully make that task easier for you.   

1. 1. First, separate the damaged from the undamaged items, and protect repairable and undamaged items from further damage as per the policy
requirements.
2. 2. Attach any documentation you may have, such as receipts, cancelled checks, credit card slips, warranty booklets, operating instructions, or
photographs to support ownership and the cost of items.
3. 3. If you are unable to provide receipts or verification of amount paid, standard pricing will be used.
4. 4. If you have any questions, please contact your claim specialist at 1-800-423-6071.
5. 5. When you have completed the inventory form, sign it and mail it back to the address on top of the letter you received with the form.