Your information
*
Policy:
*
Claim Number:
D.O.L.:
*
Insured Name:
Address:
Work Phone Number:
Cell Number:
Home Phone Number:
Fax Number:
*
Email:
Claim information
Type of loss: (water, fire, etc.)
Deductible:
Coverage Info:
Type of Policy: (Commercial, Church. Etc.)
Additional information
Is there a preferred contractor in this area?
File assigned to: (examiner, in-house adj)
Contact Info:
Phone Number:
File Number:
Fax Number:
Additional Comments: