Submit A Claim

Claim Submission Form

Please complete the assignment referral form below. Upon receipt, we will assign your claim to a qualified adjuster who will contact the insured within 24-48 hours. Once your claim has been assigned to our adjuster, an acknowledgement letter will be emailed to you informing you of the name and contact information of the assigned adjuster. Please contact us with any questions you may have at 1-866-616-4516.

Full Name
First Last
Address
Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email Address
Claim Information
Insurance Carrier Name Filing Name*
Insurance Carrier Contact Number & Fax Number*
Claim Number*
Insurance Carrier Email Address
Assignment Type
- New Assignment
- Suplement
Claim Type
Attachments
Attachments 1-4
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Accepted file types: jpg, gif, png, pdf, doc, zip.
You may upload up to 4 files

Claim Submission Form

Claim Information

Attachments