Claim No.: Insured: D/L:
Address:
Item No.: Description: CSI No.:
Unit Measure: sq. ft. cu. ft. sq. yd. cu. yd. square lin. ft. lin. yd. Unit Cost: Unit Quantity:
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If depreciation applies, enter the useful life and age of structure in years:
Enter any salvage amount: and amount of any betterment:
Item price: :
Total unburdened:
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