Submit Claims (New Customer)
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Client Information (Insurance/TPA) * Company Name: * Company Phone: * Company Address: Company Fax: * Company City: * Examiner Name: * Company State: * Examiner Phone: * Company Zip: Supervisor Name: * Company Email: Supervisor Phone: Insured Information (Lender) * Last Name: Phone 1: First Name: Phone 2: Address: Phone 3: City:     State:     Zip:     Borrower (Additional Insured) Claimant: Phone 1: Address: Phone 2: City: Phone 3: State:     Zip:     Coverage Information Claim Number:     Policy Type:     Policy #:     Effective Date:     Deductible:     Lienholder:       Amount A:       Is there APS (B) Coverage?  Yes No   Is there Contents (C) Coverage?  Yes No   Is there A.L.E. (D) Coverage?  Yes No Loss Information Loss Type: Fire Plumbing Leak Roof Leak Flood Vandalism Theft Wind Other * Loss Date: Loss Location:     Is there Cause & Origin Investigation authorized at this time? Yes No Is there Leak Detection authorized at this time? Yes No Loss Description: Authentication: