Please fill in the form as complete as possible. When you are finished, click "Submit". If necessary, we will contact you shortly to discuss this file with you.




Please Enter Your Info

Your Name:
Company:
Address:
Address:
City:
State:
Zip Code:
Phone:
Extension:
Fax:
Email:
Please Enter Your Insured's Info
Insured Name:
Insured Contact:
  
Address:
Address:
City:
State:
Zip Code:
Phone:
Extension:
Fax:
Email:

Please Enter The Loss Info

Loss Date:
Claim Number:
Claim Amount:
Can We Contact the Insured?  Yes YES   No NO
Are Other Parties Insured? Yes    No NO


What Type of Loss Is This Claim? (select all that apply)
 Catastrophe
 Liability
 Transportation/Handling
 Computer Virus and Intrusion
 Lightning
 Water
 Data Losses
 Power Surge
 Fire
 Theft
Other:

Which Services Will You Require? (select all that apply)
 Onsite Inspection
 Damage Verification
 Invoice Review
 Repair vs. Replacement
 Large Loss Emergency Response
 LKQ Verification
 Lightning Verification
 Inhouse Testing
 ACV/RCV Calculation
 Subrogation Analysis
 Verify Cause of Loss
 Salvage
 Data Recovery
 Expert Witness
 Project Management
Other:

What Is The Primary Equipment Involved In The Claim? (select all that apply)

 911 Emergency Response Equipment
 Commercial Equipment
 Fire Protection Systems
 Manufacturing Equipment
 POS Systems
 Software
 ATMs
  Computers and Networks
 High Voltage Systems
 Medical Equipment
 Printing Equipment
 TV/Radio Broadcast Equipment
 Audio/Video
 Electrical Distribution Systems
 HVAC Systems
 Office Equipment
 Residential Electronics
 Automotive Diagnostic Equipment
 Elevators and Escalators
 Industrial Equipment
 Phone Systems
 Security Alarms
 Telecommunications Equipment
Other:


Please Provide A Brief Summary Of The Claim.





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