McCloud Claims Service Inc.

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* Company Name:

*Company Address:

*Phone:

Fax:

Email address:

*Date & Time Submitted:

*Received From:

*Report to:

Type of Loss:

Policy Dates:

Coverages:

Deductible:

Claim Number:

Policy Number:

Date Of Loss:

Loss Location:

Type of Assignment?

Full Adjustment
Appraisal
Investigation
Ltd. Assignment

Insured Information

Name:

Address:

Home Phone:

Work Phone:

Property:

Property Location:

Vin or Lic:

Damages:

Estimate(s):

Claimant Information

Claimant:

Address:

Home Phone:

Work Phone:

Property:

Property Location:

Vin or Lic:

Damages:

Estimate(s):

Comments/Instructions:

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* Company Name:
*Company Address:
*Phone:
Fax:
Email address:
*Date & Time Submitted:
*Received From:
*Report to:
Type of Loss:
Policy Dates:
Coverages:
Deductible:
Claim Number:
Policy Number:
Date Of Loss:
Loss Location:

Name:
Address:
Home Phone:
Work Phone:
Property:
Property Location:
Vin or Lic:
Damages:
Estimate(s):

Claimant:
Address:
Home Phone:
Work Phone:
Property:
Property Location:
Vin or Lic:
Damages:
Estimate(s):