LINCOLN:
8300 PIONEERS BLVD.
SUITE 201
LINCOLN, NE 68506

TAMPA:
10006 CROSS CREEK BLVD.
# 452
TAMPA, FL 33647

TULSA:
9726 E 42ND ST.
STE 203
TULSA, OK 74146

PHONE: 800.354.5732
FAX: 800.255.9708
claims@alternativeclaims.com
Please select the type of assignment:
PROPERTY      LIABILITY      AUTO      CATASTROPHE

DATE

PRODUCER

PHONE

POLICY NUMBER:

CLAIM NUMBER:

POLICY INCEPTION DATE:

POLICY EXPIRATION DATE:


INSURED
NAME & ADDRESS OF INSURED:

PHONE 1:

PHONE 2:


LOSS
DATE OF LOSS:

LOCATION OF LOSS:

KIND OF LOSS:

DESCRIPTION OF LOSS:


POLICY INFORMATION
MORTAGEE:


HOMEOWNER POLICIES SECTION:
DWELLING:

CONTENTS:

OTHER STRUCTURES:

PERSONAL PROPERTY:

LOSS OF USE:

DEDUCTIBLES:

FORMS:


AUTO POLICIES SECTION:
CLAIMANT:

CLAIMANT PHONE:

CLAIMANT ADDRESS:

VEHICLE DESCRIPTION & VIN:

NUMBER OF PASSENGERS (IF APPLICABLE):


ADJUSTER NAME:


ADJUSTER TITLE: