Single Wildfire Loss Claim Form

Single Wildfire Claim

Referring Insurer(Required)

Adjuster's Name(Required)

First Last

Adjuster's Email Address(Required)

Adjuster's Phone Number(Required)

Independent Adjuster's Name

First Last

Independent Adjuster's Email Address

Independent Adjuster's Phone Number

Subrogation Adjuster's Name

First Last

Subrogation Adjuster's Email Address

Subrogation Adjuster's Phone Number

Are damages for economic loss only?

Yes

Date of Loss(Required)

Loss Amount paid to Date(Required)

Reserves(Required)

Status of Adjustment(Required)

Open

Closed

Insured Name(Required)

Loss Location(Required)

Enter exact address or latitude and longitude, if possible.

Name of Wildfire Claim Is Believed to Result From(Required)

If unknown, please type "Unknown".

Claim Number(Required)

Insured Contact Name

Insured Contact Phone Number

Underwriting Company

Is this Claim Solely for Smoke/Ash Damage?

Yes

Loss Details

Attach Any Related Photos or Documents Here

Drop files here or

Accepted file types: jpg, png, pdf, doc, xlsx, Max. file size: 50 MB.

Multiple files can be uploaded. Zip files not supported.