Company / Contact Information
Date of Loss:		Date Assigned:
Contact with Insured:		Appointment:
Insurance Company Name:
Insurance Company Address:
Adjuster:		Phone Number: Fax Number:
Public Adjuster:		Phone Number:

Insured’s Information
Insured Name:
Location Address:
City:		Zip Code:
Home Phone:		Business Phone

If Insured is Staying Elsewhere
Temporary Address:
City:		Zip Code:
Temporary Phone:

Policy Information
Claim #		Cause of Loss:
Deductible:		Collecting Deductible:

Adjustor Instructions