Clarity Loss Review Request

Clarity Loss Review Request

Please fill out this form as completely as possible. Required information is marked with an asterisk.
Confirmation

You will receive an auto-generated Thank You once you've successfully sent your request. You will receive a confirmation email from our staff within 1 business day indicating we have received your request. If you do not receive this confirmation please let us know as soon as possible.
MULTIPLE CARRIERS

If there are multiple carriers associated with this loss, please attach a list with the percentage of responsibility and indicate this in the "additional information" box and the end of the form. Thank you.
Are you an Independent Adjuster*

YesNo
Type a question

Ms.Mr.Other
Your Name*

First NameLast Name
Carrier/Your Company*
Job Title*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone*
Extension
Cell Phone
Fax
E-mail*
In which Time Zone are you located?
Policy Number*
Claim/Event Number*
Date of Loss*

MonthDayYear
Type of Business*
Type of Equipment (i.e. Restaurant, Gas Pump, Electronics, Phone System)*
Cause of Loss*
Review Type*

Site Visit RequestedDesk Top Review
Which value would you like us to determine?*

RCV OnlyACV OnlyBoth RCV & ACVFMV in Place of ACV
Is a Public Adjuster Involved?*

YesNo
Public Adjusting Company
Public Adjuster's Name

First NameLast Name
Public Adjuster's Phone #
Name on Policy*
DBA if Applicable
Loss Location Address*

Street Address 1

Street Address Line 2

CityState

Zip Code
Insured's Contact Name*

First NameLast Name
Insured's Contact Phone #*
Extension
Insured's Contact Cell #
Insured's E-mail
Alternate Contact

First NameLast Name
Alternate Contact Phone #
Extension
Helpful Information: Please check all that apply

It is OK for Clarity to contact the insuredThere are photos availableThere are quotes or proposals availableThere are original invoices availableWork has already been completed and invoicedThere is coinsuranceThere are coverage limit concerns
Limits
Supporting Documentation
Please let us know how you will send documentation*

I have no supporting documents/photos at this timeI will email documents/photos to info@clarityequip.com -include claim number/nameSupporting documents/photos have been uploaded to this form using the links below
Upload a File

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Upload a File

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Upload a File

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Upload a File

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Upload a File

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Please let us know if there is any additional information we should be aware of:
I have read and understand the following:*

Submission Confirmation: A "Thank You" screen will pop up if you successfully submit your request. If you do not see this, please check for errors highlighted in red. You should receive an email or call within 24 business hours confirming receipt of your request. If you do not receive this confirmation, please call us at 330-929-5956. Thank you for using Clarity Equipment Evaluators!
Should be Empty:

Clarity Loss Review Request

Confirmation

Supporting Documentation