TYPE OF LOSS
*
WATER MIT
MOLD
PACKOUT
BIO
FIRE / SMOKE
ABATEMENT
Source of Loss:
CARRIER ADJUSTER INFORMATION
Insurance Co:
*
Name:
*
Email:
*
Phone:
*
Please enter a valid phone number.
IN REFERENCE TO
Claim #:
*
Date of Loss:
*
-
Month
-
Day
Year
Date
Insured:
*
Insured Phone:
Please enter a valid phone number.
Contractor:
Contractor Phone:
Please enter a valid phone number.
Contractor Contact Name:
Contractor Contact Phone:
Please enter a valid phone number.
Contractor Email:
example@example.com
Loss Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
NEW ASSIGNMENT DIRECTIVE
Type a question
*
Provide Comparative Estimate
Obtain Document from XactAnalysis
Contact Vendor to Negotiate
Obtain Records from Vendor
Contact Adjuster to Review
Audit Only - Do Not Negotiate
Other
ADDITIONAL INSTRUCTION / INFORMATION
Please provide any additional information or instruction in this text box, if necessary.
Please attach documents here
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit Assignment
Should be Empty: