Claim Assignments
If you are an insurance adjuster familiar with our products, please feel free to use this form. Otherwise, please email, call, or text us using the blue button at the bottom right of the screen. Data collected is not shared with any third parties.
Claim Number
*
Insured Name
*
Is the point of contact different than the insured?
Yes
Point of Contact Name
*
Insured/POC Phone
*
Please enter a valid phone number.
Insured/POC Email
example@example.com
Insured/POC Notes
Add secondary phone numbers or special instructions here.
Inspection Address
*
Unit Number (if applicable)
Access Instructions
Please let us know if there is a gate code or special access instructions
Service(s) Requested
*
Mold Assessment & Protocol
Cause & Origin Assessment (no protocol)
Cause & Origin Assessment with Protocol
Post-Remediation Verification
Peer Review
Asbestos Survey
Other
(Asbestos) Is this for renovation or demolition?
*
(Asbestos) How big is the area that is being renovated or demolished?
*
(Asbestos) Is this related to fire damage?
*
(Asbestos) Is the inspection for interior, exterior, or both?
*
(Peer Review) Are there any specific questions you would like to have answered by this review? (Examples include duration, suspected causation, costs, etc.)
*
(Peer Review) Are there any documents that are for reference only and you do not want reviewed?
(Peer Review) Can you provide any other relevant documents? (Adjuster floor plan diagrams or photo sheets are particularly helpful.) Please upload them at the bottom.
Loss Date
-
Month
-
Day
Year
Date
Loss Details/Reason for Inspection
*
Please include the reported cause of loss or attach a loss statement at the bottom of this form.
Billing Party Company
*
Billing Party Name
*
Please provide the first and last names of the claim representative.
Billing Party Email(s)
*
example@example.com;billing@example.com
Billing Party Phone
Please enter a valid phone number.
Billing Party Address
Do you need us to share pricing with you before scheduling the work?
*
Yes
No
File Upload
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