Assign A Claim | International Contents Experts ("Inconex") © 2008

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1. INSURED CONTACT INFORMATION
Date Reported:
Date of Loss:
Claim Number:
Insured:
Name:	(If other than insured.)
Home #:
Cell #:
Email:
Community Name:
Gated Community:
Address 1:
Unit #:
City:
State:
Zip:
County:

Contact

None

2. I AM...

an Adjuster working directly for the Carrier
an Independent/Vendor/Attorney.

Independents:

Vendor:

Lawyers:

Full Name:

Phone:

Include extensions, if any.

Email:

CARRIER INFORMATION
Carrier:	(Please specify.)

3. Additional Information:

4. Cause/Type of Loss:		5. Loss Origin:	6. Inspect:
Fire (Light) Fire (Medium) Fire (Heavy) Fire (Grease) Water (Floor bound) Toilet Bathroom Sink Kitchen Sink Dish Washer Ice Maker Sewage Clean Washer Water (From Above) A/C Roof Other Sewage Clean Electric Surge Burglary Catastrophe Other (please specify)		Kitchen Bathroom Laundry Room Bedroom Garage Living Room Dining Room Den Other (please specify)	Cabinets Furniture Art Work General Contents Rugs Electronics Other (please specify) Number of Contents to Inspect:

7. Depreciation/ACV must be determined when assigning a claim.
	Yes No

8. File Attachments
I need to upload files after my claim has been submitted.

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Pompano Beach, FL 33069

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