This form is for Insurance Carrier representatives (Claims Managers, File Reviewers, Adjusters, etc. If you are not associated with the policyholder, please fill-out the Policyholder Form.) Please complete all fields that apply to your claim below, so we can best assist you. It is especially important that you provide your email address and phone number with area code as we may require additional information.

Carrier Information:     Insurance Company:   Representative Name: Representative Address:   City:   State:   Zip:         Rep Phone: Area Code:   Phone: Ext: Fax: Area Code:   Fax: Email:         Claim Information:     Insured Name:   Loss Address: Loss City: Loss State: Loss Zip:       Insured: Area Code: Daytime Phone: Work Num: Area Code: Evening Phone: Mr. Insured Cell: Area Code:   Mr. Cell: Mrs. Insured Cell: Area Code:   Mrs. Cell: Claim/Damage Type:   Fire Water Wind Hail Theft     Other: Type of Policy: Choose all that applies to your claim. Is your dispute only about your Home or Building? Are you disputing your Contents items as well? Check all that apply.   Homeowners / Dwelling or Fire Policy Structure Contents Other Structures ALE Business Policy Building Business Personal Property Other Structures Business Interruption       Date Of Loss:         Claim/Policy #'s:   Claim #           Policy #       Comments and Additional Questions:         How did you hear about us?