Business-Loss Claims Form - LIPA Claims for Power Outage & Lost money

Business-Loss Claims

Name:

Address:

Email Address:

City:

Zip Code:

Company Name:

Work Phone Number:

Cellular Phone Number:

Home Phone Number:

Type of Business:

If Other Please Specify:

Date Outage Started:

Select Date

Date Outage Ended:

Select Date

For how many days did your business lose power?:

Documents You'd Like Us To See/Review:

Pictures You'd Like Us To See:

How much money do you believe your business lost as a result of the power outage?:

Comments:

Kenneth Mollins PC | Parker Waichman LLP | Douglas & London

Disclaimer: Please note that by submitting this information, you are not filing a Notice of Claim with LIPA. As a law firm, we must first receive a signed retainer agreement after we have reviewed and accepted your case. Once retained, we can then file a Notice of Claim on your behalf.