Report a Claim

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Have you submitted a claim form but need to upload documents?

Insured Information indicates a required field
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?

We will ask you to upload this file in the next step.

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?

We will ask you to upload these files in the next step.

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?

We will ask you to upload this file in the next step.

Do you have a signed copy of your inspection agreement?

We will ask you to upload this file in the next step.

Are there any photos available?

We will ask you to upload these files in the next step.

Digital Signature:
(print name)
Date:
Spam Protection:
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