Please fill in the form as best you can and note that blue fields are required. When you are finished, click "Submit". If necessary, we will contact you shortly to discuss this file with you.

You may also download this form and fax it to us at 608-237-7422.

Please Enter Your Info Please Enter Your Insured's Info
Your Name: Insured Name:
Your Title: Insured Contact:
Company:    
Address: Address:
Address: Address:
City: City:
State: State:
Zip Code: Zip Code:
Phone: Phone:
Extension: Extension:
Fax: Fax:
Email: Email:
Please Enter The Loss Info
Loss Date:    
Claim Number: Claim Amount:
Can we contact the insured? Yes: No:
Are other parties involved? Yes: No:
What Type of Loss Is This Claim? (select all that apply)
Catastrophe Computer Virus and Intrusion Data Losses Fire
Liability Lightning Power Surge Theft
Transportation/Handling Water     
Other:
Which Services Will You Require? (select all that apply)
Data Recovery Large Loss Emergency Response ACV/RCV Calculation Causation
Damage Verification Documentation Expert Witness In-house Testing
Invoice Auditing Lightning Verification LKQ Verification Project Management
Repair vs. Replacement Subrogation Analysis Salvage   
Other:
What Is The Primary Equipment Involved In The Claim? (select all that apply)
911 Emergency Response Equipment ATMs Audio/Video Automotive Diagnostic Equipment
Commercial Equipment Computers and Networks Electrical Distribution Systems Elevators and Escalators
Fire Protection Systems High Voltage Systems HVAC Systems Industrial Equipment
Manufacturing Equipment Medical Equipment Office Equipment Phone Systems
POS Systems Printing Equipment Residential Electronics Security Alarms
Software TV/Radio Broadcast Equipment     
Other:
Please Provide A Brief Summary Of The Claim.
Accompanying Documents Can Be Faxed To 608-237-7422
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