Report a Claim

• indicates a required field

Insured Information

Business Name:
Contact Name:
Phone Number:
Cell Phone Number:
Address:
Email Address:

Policy Information

Insurance Company Name:
Policy Number:
Effective Date:
Expiration Date:
Prior Acts (Retro Date):
Retention/Deductible:

Claim Information

Claimant Name:
Claimant Address:
Claimant Phone Number:
Claimant Email Address:
Date of inspection:
Property Type:
Type of inspection:
Name of inspector(s) involved in the claim:
Date claimant discovered the issue:
Date claimant reported issue to you:
Description of claim:
Amount of claim:
Was this part of your inspection?	No Yes
Have you spoken with the claimant?	No Yes What was the nature of the conversation?
Has there been a lawsuit filed or have you been contacted by an attorney?	No Yes Attach copy here: If lawsuit what is the date of service? Claimant attorney: Claimant attorney address: Claimant attorney phone number: Claimant attorney email address:
ANY correspondence with claimant including emails?	No Yes Attach copy here:
Did the inspector admit guilt orally or in writing?	No Yes
Did inspector visit the site after the claim to discuss with the claimant?	No Yes

Additional Information

Do you have a copy of your inspection report?	No Yes Attach copy here:
Does inspection agreement include an arbitration clause?	No Yes
Are there any photos available?	No Yes Attach photo(s) here: + Add another photo
Digital Signature: (print name)
Date:
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