Please use the form below to submit your information. You may attach up to 6 files, if you need to attach more please select “YES” at the end of the form. Someone will get back to you ASAP.
Client name: (required)
Adjuster or Client contact name:
Client Email: (Required)
Client Phone Number:
Your Claim No.:
Date of loss:
Amount Paid (Amount Paid should not include deductible):
Deductible Amount:
Is Claim Amount Final? YesNo
(Please select NO is you have reserves pending)
Insured Name:
Has this assignment been worked by another agency: YesNo
(If other agency has worked the contingency rate will increase according to the agreement discussed)
Third party Driver: Third party Driver Address: Third party Driver Telephone:
Third party Owner Name: Third party Owner address:
City & State loss occurred: Address of loss location: Description of loss:
Additional Comments or special instructions:
Need to Attach more Files?: (if yes, someone will contact you asap.) YesNo
