Adjuster - Claim Rep Information:

Company Name:

Office Location:

Name:

Work Phone:

Extension

Fax:

Cell Phone:

Email:

Adjuster Street Address:

Adjuster City:

Adjuster State: State... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Adjuster Zip:

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Insured's Information:

Insured's Name:

Insured's Street Address:

City:

State: State... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Home Phone:

Work Phone:

Ext.:

Cell Phone:

Email Address:

Fax:

Other Contact Information (Atty., P.A., other family member):

Claim Information:

Claim Number:

Date of Loss:

ACV or RCV:

Deductible: $

UPP Policy Limit:$

Additional vendor support - (If Applicable) Please provide the name and phone number of the drycleaner, pack out company or restoration company that has been assigned. Please identify a contact person.

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Loss Site Information:

Please provide a brief description of the structure and the extent of damage: If you can estimate overall square footage, number of rooms, and number of occupants, it will assist us in determining the make up of our inspection team.

Other Information: