Statewide Subrogation Services Submission Form

New Submission Form

Statewide Subrogation Services, L.L.C.
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Adjuster Name*

First NameLast Name
Adjuster Email*
example@example.com
Adjuster Phone Number
Please enter a valid phone number.
Extension
Please enter a valid extension if applicable.
Adjuster Insurance Company Name*
Adjuster Third-Party Administrator Company Name (If Applicable)
Insured - Full Name

First NameLast Name
Insured Loss Location - Street Address
Insured Loss Location - City
Insured Loss Location - State
Insured Loss Location - Zip Code
Claim Number
Policy Number
Date of Loss

MonthDayYear
Date
Loss Type
Client Claim Status?

Claim CompletedIn Progress
Deductible Apply for Recovery?

YesNo
Deductible
Total Loss Amount
Total Expense Amount
Description Of Loss
At-Fault Party - Name
At-Fault Party - Street Address
At-Fault Party - City
At-Fault Party - State
At-Fault Party - Zip Code
At-Fault Party - Contact Information
Phone Number and/or Email Address
At-Fault Party - Insurance Information
Insurance Co., Policy Number, and Claim Number (If Applicable)
Please upload all important documentation to assist the recovery process!
- At-Fault Party (Name, Address, Contact, and Insurance Information).
- Policy Declaration Page.
- Copy of All Checks.
- Photographs.
- Remediation Estimates, Repair Estimates, Invoices, and/or Receipts.
- On-Site Inspection Reports, Police Reports, Fire Reports, Plumber Reports, Expert Reports, Engineer Reports, ISO Report, Etc.
- Written Statements.
If submission is unsuccessful with upload, please email documents to support@statewidesubrogationservices.com and include your claim number.

Service Fee: Statewide Subrogation Services, L.L.C. commission fee is 25% of the gross recovery. There is no charge until recovery is achieved. Please see terms & conditions below for more details.
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New Submission Form