Assign a Claim Assign Claim Intake Form If you are human, leave this field blank. Claim Number * Insurance Company * AAA Insurance Allianz Global American Family Insurance American International Group American Modern American National American Reliable Ameriprise Financial Aspen Specialty Bedford Grange Mutual Berkshire Hathaway California Fair Plan Chubb Limited Church Mutual Cincinnati Insurance Country Financial Erie Insurance Farmers Farmers Alliance Florida Family Insurance Florida Specialty Claims FM Global Frontline Insurance GEICO GeoVera Advantage Grange Insurance GuideOne Insurance Ironshore K and K Insurance Lexington Insurance Liberty Mutual Lloyd's of London Mercury Insurance NatGen Premier National General National Indemnity Nationwide Navigator Other Pacific Specialty Philadelphia Insurance Proctor Financial PURE Insurance Quincy Mutual Group SAFECO Safe Harbor Insurance Selective Insurance Self-Insured Sentry Insurance Shelter Insurance Spinnaker State Auto Insurance State Farm Insurance Tokio Marine America Travelers USAA US Coastal Insurance Western Reserve Group 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 Uploading Files. Please Wait. 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
