General Liability or Auto Loss Form

Please complete the claim form below, then click Submit to send the claim to Associated Adjusters. Click Reset to clear all fields in order to erase errors or prepare to send another claim.
Supervisor's Name:
Company:
Company Address:
Area Code/Telephone Number:
Faximile:
E-Mail Address:
Insured Contact Name:
Insured Company/ Organization/ Household:
Insured Address:
Area Code/ Telephone Number:
Faximile:
E-Mail Address:
Date of Loss: ,
Claimant's Name:
Other Contact:
Claimant Address:
Phone 1:
Phone 2:
E-Mail Address:
Represented by Attorney: Yes
No
Attorney Contact Information:
Policy Type:
Policy Limit:
Policy Number:
Claim Number:
Other policy information: (limits, deductibles, medpay, etc.)
Description of Loss/Accident, Witness Contact Information, Other Information and Instructions:

 

©2012 Associated Adjusters, Int'l. All rights reserved.

This site designed and maintained by Designer Websites.
Member of National Association of Independent Insurance Adjusters





Technology





2909 13th Street,
Suite 210
  P.O. Box 357 (39502)
  Gulfport, MS 39501
  Phone: (228) 865-9181
         (800) 528-3629   Fax:    (228) 868-1372
  E-mail: Info@Associated-Adjusters.com