Submit a Claim

Select one of the following

Licensed Insurance Carrier

Independent Adjusting Firm

Claim Handler *

Insurance Carrier *

Reporting Branch Office *

Phone (Office) *

Phone (Mobile)

Claim Handler Email *

Fax

Select one of the following *

Attached is the insured's loss inventory

Please contact insured to obtain loss inventory

Attach files

Insured's DBA *

Contact Name *

Claim Number *

Date of Loss

City

State *

Phone

Email

Select one of the following *

Evaluate only: do not facilitate replacement at this time

Evaluate & replace: immediately contact insured to facilitate replacement

Select one of the following *

RCV coverage

ACV coverage

Policy Limit (coverage and/or per item)

Deductible Amount

Select one of the following

Carrier to satisfy deductible w/insured (expedites replacement process)

RTF to collect deductible from insured

Special Instructions

Submit