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04 / 26 / 2024
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Claims Submission Form
Company
Company :: Name of your company.
Adjuster Name
Adjuster Name :: Your name goes here.
Address 1
Address 1 :: Use the next two boxes for mailing and physical addresses.
Address 2
City, State & Zip
City, State & Zip :: Example: Anchorage, AK 99501
Office
Office :: Your office phone number here.
Fax
Fax :: Your Fax number goes here.
Cell Phone
Cell Phone :: Your cell phone goes here.
Email Address
Email Address :: Your email address goes here. REQUIRED.
Claim Number
Claim Number :: Unique claim or file number your want referenced on the report.
Claim Type
Choose Option
Admiralty
Appraisal
General Liability
Garage Keeper
Marine
Other
Property
Truckers
Check All That Apply
Auto
Bodily Injury
Coverage Issue
Commercial Policy
Fatality
Fire
Freeze Up
Heavy Equipment
Heavy Trucks
Homeowners Policy
Litigation
Physical Damage - Insured
Property Damage to Others
Product Liability
Theft
Water
Vandalism
Check All That Apply :: Click the check box if it applies to your claim.
Date of Loss
Date of Loss :: Date of Loss is REQUIRED.
Insured Contact Info
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
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
Fact of Loss : Also included any specific instructions for file handling :: Describe facts of loss.
Upload a File
Upload a File :: Send an document to us; i.e. assignment sheet, policy, etc. We prefer PDF format.
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