Independent Appraiser Form


This form is for policyholders or their representatives (public adjusters, attorneys, contractors, etc.). 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.

Loss Address: (place of damage)
Mailing Address:   Same As Above.
Mailing Street:  
Mailing City:  
Mailing State:  
Mailing Zip:  
Home Num: Area Code: Home Phone:
Work Num: Area Code: Work Phone:
Mr. Cell: Area Code:   Mr. Cell:
Mrs. Cell: Area Code:   Mrs. Cell:
Fax: Area Code:   Fax:
Comments and
Additional Questions:
Claim/Damage Type:  
I am the [ - - - ] on this file:
Choose the one that
applies to you.
Policyholder (person who pays the insurance premium)
Public Adjuster for Policyholder
Attorney for Policyholder
Contractor for Policyholder
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
Home/Condo/Townhouse Contents
Other Structures ALE
Business Policy
Building Business Personal Property
Other Structures Business Interruption
Insurance Company:  
Date Of Loss:  
Claim/Policy #'s:   Claim #
    Policy #
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Insurance Claims Group, Inc. 2054 Kildaire Farm Road, Suite # 426, Cary, NC 27518
PH: (919) 669-9111 FX: (919) 573-9595 -

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Joe Brennan