Home About Us Services Locations Contact Us Careers Links Assignment Date Company Name: Report To (or submitted by) Reporting Details Phone: Fax: Email Address: Insured Information Name of Insured: Address of Insured: Home: Cell: Submit a claim using your own Loss Form Claims can be uploaded in .doc, .docx and pdf format only. Additional Comments (optional) Reporting Address: Phone: Fax: Type of Loss Type of Loss: Property Auto Liability Worker's Compensation Other Claim Details Type of Claim: Full Assignment Limited Assignment Property Appraisal Casualty Assignment Task/Select Services Claim: Yes No Special Instructions: Refer to Client Instructions for Special Agreement Call Handling Adjuster for Additional Instructions Other Information: Required Services Recorded Statement Signed Statement Insured Claimant Witness Other Casualty Scene Investigation Diagram and Measurements Photos Other Activity Check/Canvass Neighborhood Claimant Witness Other Scene Photo and Diagram Loss Details Claim Number: Date of Loss: Description of Loss: Location of Loss: Property Inspection: At Loss Location At Insured Location At Claimant Location Policy Number: Coverage Personal Lines: Homeowner Auto Dwelling Policy Other Form Version and Date: Commercial Lines: Commercial General Liability Business Owners Policy Other Form Version and Date: Vehicle of Insured Year/Make/Model: Vehicle Vin/Tag Number: Driver (if not insured) Home | About Us | Services | Locations | Contact Us | Careers | Links Collins & Company, Inc 555 River Street, Chattanooga, TN 37405 (423) 265-0541 - office (423) 265-0545 - fax Site Maintained by Interactive ID, Inc.

Home About Us Services Locations Contact Us Careers Links Alabama Home | About Us | Services | Locations | Contact Us | Careers | Links Collins & Company, Inc 555 River Street, Chattanooga, TN 37405 (423) 265-0541 - office (423) 265-0545 - fax Site Maintained by Interactive ID, Inc.