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Assign A Claim

Fields marked with an asteriks () are required. Need to upload files for a previous claim? Click here
1. Insured Contact Information
Date Reported:
Date of Loss:
Claim Number:
Insured:
Name:
(If other than insured.)
Home #:
Cell #:
Alt. #:
Email:
Community Name:
Gated Community:
Address 1:
Address 2:
City:
State:
Zip:
County:
2. I am...
an Adjustor working directly for the Carrier
an Independent/Vendor Hired by the Carrier.
3. PA or Contact Information
Name:
Office #:
Cell #:
Fax #:
Email:

7. Additional Information:
7. Inventory to be Supplied By:
4. Cause/Type of Loss: 5. Loss Location: 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
     Other (please specify)
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
Electrics
Other (please specify)

8. Depreciation/ACV must be determined when assigning a claim.

   

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