Submit a Claim

To Submit a claim you can call us (1.888.212.5815), email us ([email protected]) or fill in the form below:

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Claim Information

Claim Number*

Date of Loss*

Pre-Approved Nightly Rate

ALE Limits

Type of Policy*

Type of Loss*

Adjuster Information

Adjuster Name*

First Last

Adjuster Company*

Adjuster Phone*

Adjuster Email*

Adjuster Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Adjuster Information

Hotel Approval

Nights Approved

Estimated Check-In Date

Long Term Housing Approval

Estimated Length

Policy Holder

Policy Holder Name*

First Last

Policy Holder Phone*

Policy Holder Email

Policy Holder Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of Adults

Number of Children

Fully Serviced

Pets?

Smoker?

Special Accessibility Required?

Comments

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