Accurate, Efficient,

& Deligent

Property Claims

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Your Name*

Company Phone*

Company Name*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Office Fax

Claim & Assignment Details

Claim Number*

Policy Number

Initial Report Due*

Assignment Level*

Date of Loss*

Type of Loss*

Cat #

Loss Location

Loss Location Address City State ZIP Code

Insured's Name*

Insured's Address

Street Address City State ZIP Code

Insured's Contact Person*

Phone*

Alternate Phone

Claimant

Phone

Alternate Phone

Facts of Loss (Description)

Assignment Instructions

Coverage Information

Dwelling Coverage

Other Structures

Contents Coverage

Loss of Use

Deductable

Building Coverage

Building Deductable

Building Contents Coverage

Building Contents Deductable

Additional Coverage or Endorsements

Agent Name*

Agent Phone*

Name

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Accurate, Efficient,

& Deligent

Property Claims

Claim & Assignment Details

Coverage Information

Contact Information