Assign a ClaimAssign a ClaimWhat State is Loss Located?(Required)AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDate of Loss(Required)Address of Loss(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Policyholder Name(Required) First Last Additional Policyholder Name First Last Policyholder Email(Required) Policyholder Phone(Required)Name of Person Completing Form First Last Your Company NameYour PhoneYour Email Contractor InformationCompany NameContractor PhoneContractor Email Referral Source if not ContractorSource EmailType of Loss(Required)Please SelectCommercialResidentialBrief Description of the loss/damage(Required)What type of assignment?Public AdjustingAppraisalLitigated SupportMediation /Loss ConsultingDuplicateSupplementOtherIf Supplement Dollar Amount Paid/NotesPlease Choose OnePlease SelectFireWindHailMediation /Loss ConsultingWind/HailHurricaneWater DamageFloodPipe Break/LeakVandalismOtherInsurance Company(Required)Policy Number(Required)Status of Claim(Required)Please SelectDeniedNewSupplementOtherClaim NumberFile Upload Drop files here or Select filesMax. file size: 256 MB. NotesRequest InternalInitial Client MeetingInitial InspectionSupplementCarrier InspectionEngineering InspectionEstimateSupplementLitigated SupportDuplicateTeam LeadMediationAppraisalOther