Submit a Claim FROM: Adjuster (First & Last name): Insurance Company: Phone: Ext. Email: REGARDING: Your claim number: Name of Insured: Insured's Phone: Insured's Email Address: Scheduled or Unscheduled? ScheduledUnscheduledBoth Does this claim have more than one scheduled item? Add additional items and scheduled values in the description section below. Scheduled Value Policy Limit: Item Limit: Deductible: Please add descriptions and information on all items below. Remember to identify them as scheduled or unscheduled. Enter important claim details in the Description of Loss box below. Optional: Please attach any documents or photos that may assist us with our valuation. You can attach more than one document or photo. Click to Attach File delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete Click to Attach Photo delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete delete Do we have permission to contact the insured to collect more information? YesNo Do we have permission to contact the insured to discuss our services? YesNo
