Loss Intake Form If you are human, leave this field blank. Initial Information Call Date * Caller Name * Caller Phone Number * xxx-xxx-xxxx Insurance Company * AAA Insurance Acuity Insurance AEGIS Insurance Alliance of Schools for Cooperative Insurance Programs Allianz Global Allstate American Family Insurance American International Group American Modern American National American Reliable Ameriprise Financial Armed Forces Insurance Aspen Specialty Auto-Owners Insurance Bedford Grange Mutual Berkshire Hathaway Blackboard Insurance California Casualty California Fair Plan Central Insurance Chubb Limited Church Mutual Cincinnati Insurance Co-op Insurance Country Financial EMC Insurance Erie Insurance Farm Bureau Financial Services Farmers Farmers Alliance Farmers Mutual Insurance Farmers Mutual of Omaha 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 Kemper Insurance Lexington Insurance Liberty Mutual Lloyd's of London Mapfre Insurance Mercury Insurance Miller's Mutual NatGen Premier National General National General Lender Services National Indemnity Nationwide Navigator Pacific Specialty Philadelphia Insurance Plymouth Rock Proctor Financial PURE Insurance Quincy Mutual Group RLI Insurance SAFECO Safe Harbor Insurance SECURA Security First Selective Insurance Self-Insured Sentry Insurance Shelter Insurance Spinnaker State Auto Insurance State Farm Insurance Stillwater Texas Assn. of School Boards Texas Municipal League Texas Windstorm Insurance Association The Dentists Insurance Company Tokio Marine America Travelers United Fire Company USAA US Coastal Insurance Vermont Mutual Wayne Insurance Group Western Reserve Group Westfield Insurance Zurich North America Insurance Company (if not in list above) Claim Number If a Claim Number is not available, enter the phone number without dashes Zipcode * Loss Damage Type * Fire Smoke Mold Odor Other Surface Decontamination Water At this time BioSweep does not offer services for this type of loss. We're sorry but we are unable to help you at this time. Please contact your insurance provider for another service provider that may suit your needs. Loss Location 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 Caller Details Role of Caller Agent of Insured Claims Manager Construction Consultant Contents Consultant Family Member General Contractor Industrial Hygienist Insurance Adjuster Insured Other Property Manager Public Adjuster Restoration Contractor Vendor Manager Insurance Information Insured Name * Insured Phone Number xxx-xxx-xxxx Insured Email Address Loss Details Loss Date * Loss Description * Emergency? Yes Only click this box if the caller is unwilling to accept the "Next Business Day" wait time. Then close the call with "Your call has been marked as an emergency and will be directed accordingly, Thank You." Email files to media@biosweep.com (total files size 20MB or less) Include the Insurance Company and Case # in the Subject of the email. Building Details Adjuster/Consultant/Contractor Details Biosweep Use BioSweep Technician Role Estimator Project Manager Service Provider Supervisor Technician Actual Start Time 121234567891011 : 0030 AMPM End Time 121234567891011 : 0030 AMPM Submit
