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Report a Claim

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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?
Have you spoken with the claimant?

What was the nature of the conversation?

Has there been a lawsuit filed or have you been contacted by an attorney?

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?

Attach copy here:

Did the inspector admit guilt orally or in writing?
Did inspector visit the site after the claim to discuss with the claimant?
Additional Information
Do you have a copy of your inspection report?

Attach copy here:

Does inspection agreement include an arbitration clause?
Are there any photos available?

Attach photo(s) here:

+ Add another photo
Digital Signature:
(print name)
Date:
Spam Protection:
What type of animal is Scooby Doo?

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