Carrier Information

*Company:    
*Office Location:    
*Name:    
*Email:    
Phone #   
Type:  
   

Add Claim Information

File Number: Date  Time: 2/25/2018 1:11:54 AM
*Claim Number:  Status: New Assignment
Policy Number: Insured or Claimant
*Zip Lookup:  Loss Date: ##/##/#### Required
Deductible: Units:
  Priority:
Total Loss: Loss Code:
Assignment Description:

Owner Information

Company Name    
First Name Last Name
Address1 Address2
City State
Zip    
       
Home Number Work Number
Cell Number Other Number
Email    
   
      

Insured Information

Company Name Copy In
First Name Last Name
Address1 Address2
City State
Zip    
       
Home Number Work Number
Cell Number Other Number
Email    

Claimant Information

Company Name Copy In
First Name Last Name
Address1 Address2
City State
Zip    
       
Home Number Work Number
Cell Number Other Number
Email    

Vehicle Information

Year Make
Model Type
VIN Color
Mileage Drivable
Plate State Plate Number
       
Area of Damage:

Remarks/Delivery Instructions:

Repair Facility Information

Select Type Select Facility
Select Location Select Contact
Location Name Tax ID
First Name Last Name
Address1 Address2
City State
Zip    
       
Work Number Cell Number
Other Number Email
     

Vehicle Location Information

Location Name Copy In
First Name Last Name
Address1 Address2
City State
Zip    
       
Home Number Work Number
Cell Number Other Number
Email    
     
   
 
1-800-572-8010