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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.

Assigning Adj. Full Name:

Phone:

Include extensions, if any.

Cell:

Fax:

Email:

7. Additional Information:

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.