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Submit a Claim

SERVICES REQUESTED

Check all that applies

CLAIM VALUATION

ONSITE INVENTORY VALUATION

FULFILLMENT

ADJUSTER INFORMATION

YOUR COMPANY NAME:

YOUR NAME:

CARRIER NAME:

PHONE:

EMAIL:

ADDRESS:

CITY:

STATE:

ZIP:

POLICYHOLDER AND CLAIM INFORMATION

CLAIM NUMBER:

DOL:

POLICYHOLDER NAME:

ADDRESS:

CITY:

STATE:

ZIP:

HOME PHONE:

WORK PHONE:

MOBILE PHONE:

EMAIL:

DEDUCTIBLE AMOUNT:

SALES TAX PERCENT TO APPLY:

TOTAL CONTENTS LIMIT:

ATTACH INVENTORY PAGES:

OTHER LIMITS/COMMENTS:

Fax:
817-514-0133

Mail:
Claimplus
1310 Norwood Drive
Suite 100
Bedford, TX 76022

Email:
claims@claimplusonline.com