Assign a Project

To submit a new assignment, please complete the following form. Fields marked with an * are required.

Client Information

Name*

Company Name*

Phone*

Company Address*

Email Address*

Date*

Loss Information

Insured Name*

Claim No.*

Insured Contact Name & Number*

Insured's E-mail:*

Date*

Lock Box*

Loss Location*

Contractor Information (if different from client info)

Name*

Address*

Company*

Email*

Phone Number*

Description of Loss*

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