Basic Claim Info Form - Insurance Claim Help



Basic Claim Info Form

You should email this form to the contributor who will answer your question(s). It’s sometimes necessary for us review the information contained in your declarations page to provide you with the most accurate information. A declarations page is the “cover page” of your insurance policy that includes your names, address, insurance coverage, deductible, etc. You may scan and email a copy of your Declarations page in addition to this completed form.

Please provide the following information:

• Names of all insureds.

• Your address

• Insured item [pic] [pic]

• Loss or accident date

• Loss location – city, and state

• Your insurance company name

• Name of person your claim is against and their insurance company

• Adjuster’s name and location

• Lien holder of vehicle or Mortgage company for home

• Policy description, ie, State Farm Homeowners FP-7955 CA 6-96

• Dollar amount of coverage for:

a. Home

b. Contents

c. Additional living expense

d. Vehicle

• Settlement you were offered:

• Claim settlement you expect:

• Details before, during, and after the claim event:

• Your specific questions.

• How much you are willing to pay for answers, advice, and directions* concerning your questions,

• If you don’t want to donate for your specific answers or claim assistance, please indicate why you believe we should assist with your claim. For example hardship, no credit card, claim has been settled.

In order to provide you with the most accurate answers and advice, we may need to ask for additional information or clarification. Do you authorize us to contact you?

[pic] Telephone #:

*Be assured, we won’t ask for payment until your claim questions and concerns are fully addressed.

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