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Fill out the relevant areas below to submit a claim. One of our associates will contact you within 24 hours.

Insurance Carrier or Referring Company

Name:
Address1:
Address2:
City/State/Zip:      

Referring Adjuster or Company Contact

Name:
E-mail:
Phone:
Would you rather receive the report via E-mail or Regular Mail
E-mail:
Regular Mail
 
Your Claim or File Number: #
 
Insured Name and Address
Name:
Address1:
Address2:
City/State/Zip:      
Daytime Phone:
 
Loss Location (if different from above)
Contact:
Address1:
Address2:
City/State/Zip:      
 
Coverages
Dwelling/Building:
Loss of Use/ALE:
Contents/UPP:
Deductible/Co-Insurance:
Liability per Occurrence Limit:
Liability per Aggregate Limit:
Per Claim Limit:
Aggregate Erosion:
Applicable Forms
 
Special instructions, requirements, and any other specifics related to this assignment to help ensure that we meet your needs:
 

 

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Our services also include:
• Photographs
• Estimates
• Diagrams
• Agreed Figures for Each Service, When Requested

Adjuster Certifications
• AMIM: Associate in Marine Insurance Management
• ARM: Associate in Risk Management
• AIS: Associate in Insurance Services
• CRIS: Construction Risk and Insurance Specialist
• CPCU: Chartered Property Casualty Underwriter

Please contact us with any questions or comments regarding our services:
Phone: (866) 861-0157
Emergency Number: (803) 372-9317
E-mail: info@cubitgroupllc.com