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 InsuranceAcuity InsuranceAdventist Risk Management, Inc.AEGIS Insurance CompanyAlfa Insurance CorporationAlliance of Schools for Cooperative Insurance ProgramsAllianz Global Corp. & Spec.Allstate InsuranceAmerican Family InsuranceAmerican Integrity Insurance GroupAmerican International GroupAmerican Modern InsuranceAmerican National InsuranceAmerican Reliable InsuranceAmeriprise FinancialAmGUARD Insurance CompanyArch Insurance GroupArmed Forces InsuranceAspen Claims ServiceAuto Club Enterprises GroupAuto-Owners InsuranceBadger MutualBamboo InsuranceBedford Grange Mutual InsuranceBerkshire Hathaway Specialty InsuranceBlackboard InsuranceBrotherhood MutualCalifornia CasualtyCalifornia FAIR PlanCapital Insurance GroupCatholic Mutual GroupCelina Insurance GroupCentral Insurance CompaniesCharles Taylor AdjustingChubb LimitedChurch MutualCincinnati InsuranceCNA InsuranceCo-Operative Insurance Co.Columbia Insurance GroupContinental Western GroupCOUNTRY Financial Insurance CompanyCovington Specialty InsuranceCSAA Insurance GroupEMC Insurance CompaniesErie IndemnityFarm Bureau Financial ServicesFarmersFarmers Alliance Mutual Insurance Co.Farmers Mutual InsuranceFarmers Mutual of OmahaFederated Mutual Insurance CompanyFlorida Family InsuranceFlorida Specialty ClaimsFM GlobalFrankenmuth Insurance GroupFrontline InsuranceGEICOGeoVera Specialty Insurance GroupGrange InsuranceGuideOne InsuranceHanover Insurance GroupHarbor Claims, LLCHartford InsuranceHastings Mutual Insurance CompanyHippo InsuranceHochheim Prairie InsuranceIronshoreK&K InsuranceKemper CorporationKentucky Farm BureauLexington InsuranceLiberty Mutual InsuranceLloyd's of LondonMapfre InsuranceMcNeil & Co IncMercury InsuranceMidwest Family Mutual Ins. Co.Millers Mutual InsuranceNatGen PremierNational Fire & Marine Insurance CompanyNational GeneralNational General Lender ServicesNational Indemnity Insurance GroupNational MutualNationwide GroupNavigatorNorth Carolina Farm Bureau Federation IncOklahoma Farm BureauOther - Company Not ListedPacific Specialty Insurance CompanyPalomar SpecialtyPekin Insurance CompanyPhiladelphia Insurance CompaniesPlymouth Rock AssuranceProctor FinancialProgressivePURE InsuranceQuincy Mutual GroupRLI InsuranceRural Mutual InsuranceSafe Harbor InsuranceSafeco InsuranceSECURA Insurance CompaniesSecurity First InsuranceSelective Insurance GroupSelf-InsuredSentinelSentry Insurance CompanyShelter Insurance CompaniesSpinnakerState Auto InsuranceState Farm InsuranceSteadfast Claims Service, LLCStillwater Insurance GroupSwyfft LLCTexas Association of School BoardsTexas Fair Plan AssociationTexas Municipal LeagueTexas Windstorm InsuranceThe Dentists Insurance CompanyTokio Marine AmericaTravelersUnited Fire GroupUniversal Property & CasualtyUS Coastal InsuranceUSAA InsuranceVaultVentus Risk ManagementVermont MutualWayne Mutual Insurance CompanyWest Bend Mutual InsuranceWestern Reserve GroupWestern World InsuranceWestfield InsuranceYork 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 0 of 4000 max characters 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 0 of 2000 max characters CAPTCHA If you are human, leave this field blank. Submit Start Over
