New Loss
Insurance Company.*
Claim Number.*
Client. (Attorney or Insurance Adjuster)*
Client Phone Number.*
Client E-mail.*
Client Address.
Date of Loss. (DOL)*
Name of Insured.*
Insured Contact Number. (for access)*
Public Adjuster's Name and Information. (If assigned)
Loss Address.*
Origin Unit Contact Information. (If we are an exposure property.)
Insured. (Owner or Tenant)*
Suspected Cause of Loss.*
Order a Fire Department Incident Report. (Yes or No)*
Vehicle Loss. (Yes or No) (If so please answer the following questions.)*
Vehicle Make.
Vehicle Model.
Vehicle License Number.
Vehicle Identification Number. (VIN)
Vehicle Year.
Vehicle Color.
Vehicle Location. (including lot #, if applicable)
Email Receipt Address.