Section 1 - YOUR INFORMATION

Company: *

First Name: *

Last Name: *

Email: *

Phone: *

Address:

City, State, Zip:

Section 2 - LOSS INFORMATION

Insured/Company:

First Name:

Last Name:

Contact's Relationship to Insured:

Claim Number: *

Date of Loss:

Email:

Phone:

Address:

City, State, Zip:

Section 3 - LOSS TYPE: (Please check all that apply)

LightningPower SurgeFireSmokeWaterTheftImpactWindOTR/TransportationTBD/UnknownVehicle AccidentNatural DisasterRansomware/Virus/HackerData Deletion/Hard Drive CrashOther

Section 4 - ACTIONS REQUIRED: (Please check all that apply)

CausationDamage VerificationCoordinate RepairsLightning VerificationData RecoveryExpert WitnessRepairabilityIn-House TestingRestorationInvoice ReviewEquipment RecertificationLKQ VerificationOn-Site InspectionVirus RemovalProject ManagementRCV: Replacement Cash ValueACV: Actual Cash ValueSubrogationSurge Type Lightning vs. UtilitySecure StorageOther

Section 5 - PREDOMINANT EQUIPMENT (Please check all that apply)

ComputersServersHard DrivesCommunicationsMedicalIntercom / Alarms / SecurityPrintingManufacturingHVAC SystemsElevators / EscalatorsHome Theater SystemsResidentialPoint of Sale / Cash RegistersBroadcast (TV & Radio)Electrical Distribution SystemsPolice & Fire Radio Emergency SystemsRestaurant / HospitalityOther

Section 6 - LOSS DESCRIPTION