Submit a Claim

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Section 1: Loss Information

1. State of Loss Location(Required)

State

2. Date of Loss(Required)

3. Address of Loss (Street Line 1)(Required)

Address of Loss (Street Line 2)

City(Required)

State(Required)

State

Zip Code(Required)

Zip

Section 2: Policyholder Information

4. Policyholder Name(Required)

First Last

5. Additional Policyholder Name

First Last

6.Policyholder Email(Required)

7. Additional Policyholder Email

8. Policyholder Phone(Required)

Section 3: Claim and Loss Details

9. If Commercial Entity Name

10.Cause of Loss(Required)

11. Loss/Damage Description(Required)

12. Type of Assignment(Required)

13. Supplement Dollar Amount Paid/Notes

14. Insurance Company(Required)

15. Policy Number

16. Status of Claim(Required)

17. Claim Number

Section 4: Contractor Info

Company Name

Sales Rep Name

Sales Rep Email

Sales Rep Phone

Section 5: Uploads

18. File Upload

Max. file size: 256 MB.

Section 6: Additional Notes and Requests

19. Notes

20. Name of Person Filling Out This Form(Required)