Case Report Form

Complete the form below and hit SUBMIT to begin a new Case Report. For an immediate response after business hours, on holidays or weekends, contact our emergency 24-hour line: 888-273-6644.

Person Completing This Form

Email Contact

Confirm Your Email

Loss Location

Date of Loss

Loss Notes (optional)

Insured's Name

Insured's Contact Info

Tenant Name

Case Invoicing

Law Firm

Attorney Name

Attorney Email

Confirm Attorney Email

Law Firm Address

Attorney File or Docket No

Claim Number

Insurance Company

Claim Rep

Claim Rep Phone

Claim Rep Email

Confirm Claim Rep Email

Vehicle Loss?

Type of Vehicle Loss

Vehicle Make/Model

VIN Number

Lot or Stock Number

Vehicle Location

Repair/Problem History Aftermarket Products Specialized Investigation Instruction

Independent Adjuster Company

Independent Adjuster Contact

Independent Adjuster Phone

Independent Adjuster File Number

Public Adjuster Company

Public Adjuster Contact

Public Adjuster Phone

Public Adjuster File Number

Fire Marshall

Fire Marshall Phone

Fire Marshall Address Fire Marshall Report Request Comments Other Parties Report Type/Instructions

What is 9 + 3 ?

Case Report Form

Employment Opportunities

Company Numbers

Company Info