Online Claims Request Form [ Industrial Loss Consulting, Inc. ]

Online Claims Request Form


Company Name:
Complete Address:
Adjuster:
Title:
Telephone Number:
Fax Number:
E-mail Address: (required)
Claim Number:
Date of Loss:

Company Name:
Insured Product Line:
Claim Location:
Contact Name:
Telephone Number:

Check all that apply below:
ACV
Market Cost / Used Value
Replacement Cost

(Please include all pertinent information such as model #, serial #, size)

If you have information in printed or fax form, note this in the "Claim Information" box above. Send the fax after submitting the form by e-mail. (Use Fax # 765.521.6167 for research work) When you have filled out the form completely, print a copy for your records. If you have any problems printing, let us know and we will fax you a copy. You should receive an acknowledgement of receipt via email within 24 hours. Please call if you have any questions or have not received our acknowledgement in a timely manner. We thank you for your patience and continued cooperation.

1322 Broad Street | New Castle, IN 47362
Phone: (765) 521-0648 Toll Free: (800) 497-4030 | Fax: (765) 521-0751
E-mail: info@industrialloss.com