Assign a Claim Assign Claim Intake Form If you are human, leave this field blank. Claim Number * Insurance Company * AAA Insurance Acuity Insurance Allianz Global Allstate American Family Insurance American International Group American Modern American National American Reliable Ameriprise Financial Aspen Specialty Auto-Owners Insurance Bedford Grange Mutual Berkshire Hathaway Blackboard Insurance California Casualty California Fair Plan Chubb Limited Church Mutual Cincinnati Insurance Co-op Insurance Country Financial Erie Insurance Farm Bureau Financial Services Farmers Farmers Alliance Farmers Mutual Insurance Florida Family Insurance Florida Specialty Claims FM Global Frontline Insurance GEICO GeoVera Advantage Grange Insurance GuideOne Insurance Hanover Insurance Group Ironshore K and K Insurance Lexington Insurance Liberty Mutual Lloyd's of London Mercury Insurance Miller's Mutual NatGen Premier National General National Indemnity Nationwide Navigator Pacific Specialty Philadelphia Insurance Plymouth Rock Proctor Financial PURE Insurance Quincy Mutual Group RLI Insurance SAFECO Safe Harbor Insurance SECURA Selective Insurance Self-Insured Sentry Insurance Shelter Insurance Spinnaker State Auto Insurance State Farm Insurance Stillwater Texas Municipal League The Dentists Insurance Company Tokio Marine America Travelers USAA US Coastal Insurance Vermont Mutual Wayne Insurance Group Western Reserve Group Westfield Insurance Zurich North America Other Insurance Company Name * Adjuster First Name * Adjuster Last Name * Adjuster Phone * Adjuster Phone Extension Adjuster Email * Loss Date * Loss Damage Type * Fire Smoke Odor Other Odor (describe)Other Odor (describe) Air and Surface Decontamination Mold Loss Property Type * Commercial Residential Loss Business Name Loss Address * Loss Address Loss Address Loss Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Insured First Name * Insured Last Name * Insured Phone Number xxx-xxx-xxxx Insured Email Address Additional Details Upload ACORD - Loss Notification Drop a file here or click to upload Choose File Maximum upload size: 10MB How Did You Hear About Us? Adjuster Claims Manager Vendor Panel Internet Search PLRB Event Other How Did You Hear About Us? reCAPTCHA Date Entered Submit
