Home Submit Claim Submit Claim Online
11 / 23 / 2017

Claims Submission Form

 
Company :: Name of your company.
 
Adjuster Name :: Your name goes here.
 
Address 1 :: Use the next two boxes for mailing and physical addresses.
 
 
City, State & Zip :: Example: Anchorage, AK 99501
 
Office :: Your office phone number here.
 
Fax :: Your Fax number goes here.
 
Cell Phone :: Your cell phone goes here.
 
Email Address :: Your email address goes here. REQUIRED.
 
Claim Number :: Unique claim or file number your want referenced on the report.
 
 

















Check All That Apply :: Click the check box if it applies to your claim.
 
Date of Loss :: Date of Loss is REQUIRED.
 
Insured Contact Info :: Please provide as much contact information for the insured as possible including full name, address, phone numbers (home, office, cell, fax).
 
Claimant(s) Contact Information :: Please provide as much contact information for the claimants as possible including full name, address, phone numbers (home, office, cell, fax).
 
Fact of Loss : Also included any specific instructions for file handling :: Describe facts of loss.
 
Upload a File :: Send an document to us; i.e. assignment sheet, policy, etc. We prefer PDF format.