Flooring Quick Claim

Adjuster Information

	Adjuster Name*					Last Name*
	Primary Phone*		Ext			Secondary Phone
	Email*

Insurance Company Information

Comp. Name* Address 1* Address 2 City* State* Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Deleware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip* Phone* Web Site

Insured Information First Name* Last Name* Address 1* Address 2 City * State * Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Deleware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip * Primary Phone* Secondary Phone

Location of Loss Same Location First Name* Last Name* Address 1* Address 2 City * State * Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Deleware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip * Primary Phone* Secondary Phone

Claim Information Deductible Amount * Description of Loss* Claim Number * Policy Number * Date Reported * Date of Loss * Should HSG collect Deductible? * Yes No Sample Taken?* Yes No

Restoration Contractor Company Name Contact Name Phone Branch Address Address 2 City State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Deleware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip

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