Report an Insurance Claim

PLEASE FILL OUT THE FORM COMPLETELY

FIRST NAME:

LAST NAME:

ADDRESS:

CITY:


STATE:    ZIP:

DAYTIME PHONE:    EVENING PHONE:

EMAIL ADDRESS:

HOW WOULD YOU LIKE US TO CONTACT YOU:

TYPE OF CLAIM: (check all that apply):
  Water Mitigation
  Mold Remediation
  Fire-Smoke-Soot Clean-up
  Board-Up
  Trauma
  Vandalism
   Other - please specify:

ADDITIONAL COMMENTS OR QUESTIONS:

PLEASE ENTER THE CODE SHOWN BELOW

Insurance Claim Checklist

Information to have ready
for your claim:

Name
Address
Home/business phone
Cell phone
Alternate number
Email

Date of loss
Source of loss
Is the source fixed?
Is there electricity?
Is there heat?
Types of flooring affected
Description of areas affected (rooms, walls)
Square footage

Insurance Agent and Customers