1.877.TECHLOSS
(1.877.832.4567)
fax: 1.847.541.2325

Submit a Loss

Project Initialization Form - *mandatory fields [Download the PDF]
Section 1 - YOUR INFORMATION
Insurance Legal Government Self-Insured Independent Adjusters
Other
 
Company
Contact Name*
Address
City
State
Zip Code
Telephone*
Fax Number
E-mail*
Section 2 - LOSS INFORMATION
Insured/Company
Contact Name Relationship
Alternate Contact Name Relationship
Address
City
State
Zip Code
Telephone
Alternate Telephone
Fax Number
E-mail
Alternate E-mail
Claim Number
Date of Loss
Estimated Claim Amount
Section 3 - WHY DID YOU CHOOSE TECHLOSS? (Please check & specify)
Preferred Vendor Conf./Seminar Print Ad/Web Site Direct Mailer
Referral:   Other:
Section 4 - LOSS TYPE: (Please check all that apply)
Lightning Power Surge Fire Smoke Water Mold
Theft OTR/Transportation Impact Wind
TBD/Unknown Vehicle Accident Natural Disaster
Virus/Hacker Data Deletion/Hard Drive Crash
Other
Section 5 - ACTIONS REQUIRED: (Please check all that apply)
ACV: Actual Cash Value
QCP Program
Causation
Damage Verification
Coordinate Repairs
Pre-Loss Planning
Lightning Verification
Data Retrieval		 Expert Witness
Reparability
In-House Testing
Restoration
Invoice Review
Salvage
Recertified Replacement Cost
LKQ Verification		 Nationwide On-Site Inspection
Virus Removal
Project Management
Software Recovery/Licensing
RCV: Replacement Cash Value
Data Management Solutions
Subrogation
Surge Type: Lightning vs. Utility
Other
Section 6 - PREDOMINANT EQUIPMENT: (Please check all that apply)
Computers Servers Hard Drives/Data Storage Communications
Medical Intercom/Alarms/Security Printing Manufacturing
HVAC Systems Elevators/Escalators Home Theater Systems
Residential Point of Sale/Cash Registers Broadcast (TV & Radio)
Electrical Distribution Systems Police & Fire Radio Emergency Systems Restaurant/Hospitality
Other
Section 7 - LOSS DESCRIPTION
 
 
 
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