Intake Form Intake Form Initial Information Request Date Requester Name * Requester Phone If there is an extension, type the digits after the phone number. Requester Email * Role of Requester Insurance AdjusterIndependant AdjusterConstruction ConsultantGeneral ContractorIndustrial HygienistInsuredFamily MemberRestoration ContractorTPAOther Role of Requester Insurance Company AAA Insurance Acuity Insurance Adventist Risk Management, Inc. AEGIS Insurance Company Alfa Insurance Corporation Alliance of Schools for Cooperative Insurance Programs Allianz Global Corp. & Spec. Allstate Insurance American Family Insurance American Integrity Insurance Group American International Group American Modern Insurance American National Insurance American Reliable Insurance Ameriprise Financial AmGUARD Insurance Company Arch Insurance Group Armed Forces Insurance Aspen Claims Service Auto Club Enterprises Group Auto-Owners Insurance Badger Mutual Bamboo Insurance Bedford Grange Mutual Insurance Berkshire Hathaway Specialty Insurance Blackboard Insurance Brotherhood Mutual California Casualty California FAIR Plan Capital Insurance Group Catholic Mutual Group Celina Insurance Group Central Insurance Companies Charles Taylor Adjusting Chubb Limited Church Mutual Cincinnati Insurance CNA Insurance Co-Operative Insurance Co. Columbia Insurance Group Continental Western Group COUNTRY Financial Insurance Company Covington Specialty Insurance CSAA Insurance Group EMC Insurance Companies Erie Indemnity Farm Bureau Financial Services Farmers Farmers Alliance Mutual Insurance Co. Farmers Mutual Insurance Farmers Mutual of Omaha Federated Mutual Insurance Company Florida Family Insurance Florida Specialty Claims FM Global Frankenmuth Insurance Group Frontline Insurance GEICO GeoVera Specialty Insurance Group Grange Insurance GuideOne Insurance Hanover Insurance Group Harbor Claims, LLC Hartford Insurance Hastings Mutual Insurance Company Hippo Insurance Hochheim Prairie Insurance Ironshore K&K Insurance Kemper Corporation Kentucky Farm Bureau Lexington Insurance Liberty Mutual Insurance Lloyd's of London Mapfre Insurance McNeil & Co Inc Mercury Insurance Midwest Family Mutual Ins. Co. Millers Mutual Insurance NatGen Premier National Fire & Marine Insurance Company National General National General Lender Services National Indemnity Insurance Group National Mutual Nationwide Group Navigator North Carolina Farm Bureau Federation Inc Oklahoma Farm Bureau Other - Company Not Listed Pacific Specialty Insurance Company Palomar Specialty Pekin Insurance Company Philadelphia Insurance Companies Plymouth Rock Assurance Proctor Financial Progressive PURE Insurance Quincy Mutual Group RLI Insurance Rural Mutual Insurance Safe Harbor Insurance Safeco Insurance SECURA Insurance Companies Security First Insurance Selective Insurance Group Self-Insured Sentinel Sentry Insurance Company Shelter Insurance Companies Spinnaker State Auto Insurance State Farm Insurance Steadfast Claims Service, LLC Stillwater Insurance Group Swyfft LLC Texas Association of School Boards Texas Fair Plan Association Texas Municipal League Texas Windstorm Insurance The Dentists Insurance Company Tokio Marine America Travelers United Fire Group Universal Property & Casualty US Coastal Insurance USAA Insurance Vault Ventus Risk Management Vermont Mutual Wayne Mutual Insurance Company West Bend Mutual Insurance Western Reserve Group Western World Insurance Westfield Insurance York Risk Services Group, Inc. Zurich North America Insurance Company (Other) If not listed above Claim Number * Loss Details Loss Date Loss Damage Type Fire Smoke Odor OtherOther Loss Property Type ResidentialCommercial Business Name Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Loss Description Upload ACORD Drop a file here or click to upload Choose File Maximum file size: 10MB Limited to 5 files, 10MB size limit. File Types allowed: jpg, png, gif, heic, pdf Upload Photos Drop a file here or click to upload Choose File Maximum file size: 10MB Limited to 10 files, 10MB size limit. File Types allowed: jpg, png, gif, heic, pdf Insured Information Insured Name #1 Insured Phone #1 Insured Email #1 Insured Name #2 Insured Phone #2 Insured Email #2 Referred By (Name) Additional Information CAPTCHA If you are human, leave this field blank. Submit Start Over
