CLAIM FORM

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Claim Date

Carrier

Referral Type*: RestorationMitigationAppraisal
Insured/Resident Information:

First & Last Name*

Address*

Day Time Phone Number*

Evening Phone Number

Email

Owner Information: Same as above

Owner's First & Last Name

Owner's Address

Day Time Phone Number

Evening Phone Number

Owner's Email

Policy Information:

Claim Reference Number

Policy Number

Deductible Amount

Policy Limits:

Dwelling Contents Other

Loss Information:

Loss Date

Loss type (You can choose multiple types by holding Ctrl key)
---Water or SteamSewer or Drain BackupMoldFireFloodFreezingMechanical BreakdownIce or Snow WeightNon-Emergency RepairOther Casualty LossesHurricaneTest ProjectAnimal LiabilityAircraftBurglaryCollapseCollisionContamination or PollutionEarthquakeExplosionFalling ObjectGlassHailHeat Expansion or ContractionLand SlideLightningMud SlideMoving and StorageMysterious DisappearancePower InterruptionPower SurgeRiotRobberySea WaterSinkhole or CollapseSmokeSubsidenceTheftTornadoTraumaVandalism or Malicious MischiefVehicleVolcanicWindstormAll Water CausesSmoke / Fire DamageEnvironmental (Mold / Asbestos)Sump Pump overflowOther

Additional Information about the loss

Special Instructions

Adjuster's Information:

Adjuster's First & Last Name

Independent Adjuster

Email Address to send the confirmation to

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By submitting this Claim Form, I confirm that all the information provided above are accurate.*

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