The following submittal form was built to make processing your claims faster and more simple. Every time you use this form you will get a personalized email from our claims team verifying that the claim was received.

The form is easy, just fill in all the details of the claim. To move from field to field you can use the “TAB” function. Once filled in click the “SUBMIT” button at the the bottom of the form.

If you have any difficulty with the form or just want to talk to one of our reps then simply

call our Toll Free Line at (866) 305-9683.

ADJUSTERS INFORMATION:

Adjusters Name *
Insurance Co.*
Street Address *
Address (cont.)
City *
State/Province *
Zip/Postal Code *
Business Phone *
Extension
Other Phone
FAX *
E-mail *

INSUREDS INFORMATION:

Claim Number *
Claimants Name *
Street Address
City
State/Province
Zip/Postal Code
Home Phone
Work Phone
Other Phone
E-mail

SCHEDULED ITEMS:

Total Coverage
Deductible
Deductible Absorbed?	Yes No N/A

Please insert the items with detailed description into the box. If multiple items exist place the scheduled value after each description. Most systems will allow you to cut and paste this information. If more convenient, fax the documentation to our toll free fax at (801) 606-7433

NON-SCHEDULED ITEMS:

Total Coverage
Per Item Limit
Deductible
Deductible Absorbed?	Yes No N/A

Please insert any documentation, descriptions and/or values associated with each item.