edjuster - Submit a Claim

* indicates a required field

Adjuster / Claim Information

Insurance Company

Insurer Claim Number

Adjuster Name (main claim contact)

Adjuster Email

Adjuster Phone Number

Independent Adjuster Company (if required)

Independent Adjuster File Number

Examiner Name for Insurance Company (if required)

Examiner Email

Examiner Phone Number

Date of Loss

Content Loss Estimate $

Policy Limit $

Deductible $

Special Limits

Details

Name(s)

Address

Zip / Postal Code

City

State / Province / Region

Email Address

Mobile Phone

Home Phone

Business Phone

Contractor Company Name

Contractor Contact Name

Contractor Contact Email

Contractor Contact Phone Number

Please attach supporting files or documents, such as the Statement of Loss (list of contents).

Limit of 10 files. Maximum individual file size permitted is 10 megabytes.

File Name	File Size	Actions