Assign a Claim

Claim Handler Information


Name:
Company Name:
Phone:
-
E-mail:

Claim Information


Claim Number:*
Date of Loss:
Date Reported:
Name Insured:
Policy Number:
Insured's Address:
Insured's Phone:
-
Insured's Alt. Phone:
-
Location of Accident/Loss
Description of Accident/Loss:

Claimant Information


Claimant Name:
Claimant Phone:
-
Claimant Alt. Phone:
-
Claimant's Email:
Claimant Address:
Claimant Attorney:
Attorney Phone:
-

Referral Information


Referral Date:
Due Date:
Tasks Needed:

Detailed Instructions

Upload a File:
Instructions: